Medical Director, Utilization & Quality

Molina Healthcare; Wisconsin; On-site; USD 186,000 - 363,000; Full time

Job summary

Molina Healthcare provides medical oversight to ensure appropriate and cost-effective care for members in Wisconsin, aiming to improve efficiency and satisfaction for members and providers. The role contributes to strategy and leadership in quality and outcomes across the network.

Key duties include evaluating medical necessity, guiding utilization practices, and leading compliance with NCQA/URAC, Medicare and Medicaid guidelines while educating providers and managing quality assurance

Qualifications

• At least 3 years health care experience, incl. 2 years medical practice.
• Active and unrestricted MD or DO license in state of practice.
• Board certification in medicine or related field.
• Working knowledge of applicable national, state, and local laws affecting medical staff.
• Ability to work cross-collaboratively within a highly matrixed organization.
• Strong organizational, time-management, and multi-tasking skills.
• Attention to detail, critical-thinking and effective communication.
• Proficiency with Microsoft Office and ability to learn new programs.

Responsibilities

• Determines appropriateness and medical necessity of health care services for plan members.
• Supports plan utilization management program and action plans to ensure appropriate care.
• Evaluates effectiveness of utilization management practices and monitors utilization.
• Educates and interacts with network providers and medical managers on utilization practices and guidelines.
• Assumes leadership for knowledge and training of medical-necessity criteria.
• Participates in NCQA and URAC accreditation preparation and processes.
• Reviews appeals processes and investigates quality-of-care concerns.
• Chairs or attends committees such as credentialing and P&T as directed by leadership.
• Ensures care aligns with Medicare/Medicaid/NCQA standards and regulatory requirements.
• Analyzes data to improve utilization management and patient outcomes.

Skills

Verbal communication

Written communication

Attention to detail

Critical-thinking

Decision-making

Problem-solving

Multi-tasking

Time-management

Cross-functional collaboration

MS Office proficiency

Education

MD/DO (unrestricted)

Board certification

Certifications: CPHQ/CPHM/CCMC/CMSA

Tools

Microsoft Office

Job description

Molina Healthcare provides medical oversight to ensure appropriate and cost-effective care for members in Wisconsin, aiming to improve efficiency and satisfaction for members and providers. The role contributes to strategy and leadership in quality and outcomes across the network.

Key duties include evaluating medical necessity, guiding utilization practices, and leading compliance with NCQA/URAC, Medicare and Medicaid guidelines while educating providers and managing quality assurance