Medical Director, Quality & Utilization Management

Molina Talent Acquisition; Wisconsin; On-site; USD 190,000 - 270,000; Full time

Job summary

Molina Healthcare is seeking a licensed physician to provide medical oversight and ensure appropriate care for members. You will contribute to quality initiatives, regulatory compliance, and cost-effective member care in collaboration with clinical leadership.

Responsibilities include evaluating medical necessity, leading utilization management efforts, and participating in NCQA/URAC readiness. Strong communication and cross-functional collaboration are essential to drive improved outcomes.

Qualifications

• Requires MD or DO with active license in the state
• Board certification required
• Strong knowledge of national, state and local medical regulations

Responsibilities

• Determines medical necessity of health care services for plan members
• Leads utilization management and education for providers of care
• Monitors quality and cost-effectiveness of care through UM practices
• Participates in NCQA and URAC accreditation preparation
• Provides leadership for compliance with Medicare, Medicaid and other regulations
• Reviews adverse events and ensures appropriate care delivery
• Chairs or participates in credentialing, P&T, and other committees as directed

Skills

Medical oversight

Regulatory compliance

Cross-functional collaboration

Data analytics

Education

MD/DO license

Board certification

Job description

Molina Healthcare is seeking a licensed physician to provide medical oversight and ensure appropriate care for members. You will contribute to quality initiatives, regulatory compliance, and cost-effective member care in collaboration with clinical leadership.

Responsibilities include evaluating medical necessity, leading utilization management efforts, and participating in NCQA/URAC readiness. Strong communication and cross-functional collaboration are essential to drive improved outcomes.