Director of Medical Quality & Utilization

Molina Healthcare Inc; Wisconsin; On-site; USD 180,000 - 240,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare Inc. is seeking a Medical Director to provide medical oversight for appropriateness and medical necessity of services delivered to plan members, with a focus on cost-effectiveness and quality outcomes.

The role will lead utilization management activities, collaborate with providers and clinical leadership, and drive NCQA and URAC accreditation preparation while ensuring compliance with Medicare/Medicaid standards.

Qualifications

• Active and unrestricted MD/DO license in state of practice.
• Board certification in a relevant medical field.
• Strong understanding of national, state, and local regulations affecting medical staff.
• Excellent verbal and written communication skills.
• Solid organizational and time-management abilities.
• Ability to multi-task and meet deadlines.
• High attention to detail and analytical thinking.
• Strong problem-solving and decision-making abilities.
• Proficiency with Microsoft Office applications.

Responsibilities

• Determines appropriateness and medical necessity of health care services for plan members.
• Supports utilization management programs and related action plans.
• Educates and interacts with providers and medical managers on utilization practices.
• Leads and mentors on use of medical necessity criteria.
• Participates in and maintains integrity of appeals processes.
• Reviews quality issues and recommends corrective actions.
• Participates in NCQA and URAC accreditation preparations.

Skills

MD/DO license

Board certification

Regulatory knowledge

Communication skills

Time management

Multi-tasking

Attention to detail

Critical thinking

Problem solving

MS Office

Job description

Molina Healthcare Inc. is seeking a Medical Director to provide medical oversight for appropriateness and medical necessity of services delivered to plan members, with a focus on cost-effectiveness and quality outcomes.

The role will lead utilization management activities, collaborate with providers and clinical leadership, and drive NCQA and URAC accreditation preparation while ensuring compliance with Medicare/Medicaid standards.