Medical Director - Utilization & Quality Improvement

Molina Healthcare; Madison (WI); On-site; USD 186,000 - 363,000; Full time

Job summary

Molina Healthcare in the United States seeks a physician leader to provide medical oversight and expertise in appropriateness and medical necessity of services for plan members, with a focus on improving efficiency, patient satisfaction and care quality in the most effective setting.

You will support utilization management programs, lead clinical quality improvement, participate in NCQA/URAC compliance, educate networks and medical staff, and ensure care delivery meets regulatory standards

Qualifications

• At least 3 years health care experience including 2 years medical practice.
• Active and unrestricted MD or DO license in state of practice.
• Board certification required; professional certifications preferred.
• Working knowledge of national, state, and local regulatory requirements.
• Ability to work across a matrixed organization with strong communication.

Responsibilities

• Determine appropriateness and medical necessity of care for plan members.
• Support utilization management programs and action plans for high-quality care.
• Evaluate effectiveness of utilization management practices.
• Educate providers and medical managers on utilization practices and resource management.
• Lead knowledge and implementation of medical necessity criteria.
• Participate in NCQA and URAC accreditation processes.
• Provide leadership for NCQA standards and quality improvement activities.
• Ensure conformance to Medicare, Medicaid, NCQA and other regulatory requirements.
• Review quality issues, conduct retrospective reviews, and resolve grievances.
• Attend or chair committees such as credentialing and Pharmacy and Therapeutics.

Skills

Cross-functional collaboration

Time management

Attention to detail

Critical thinking

Communication skills

Multitasking

Microsoft Office proficiency

Education

MD or DO licensed

Board certification

CPHM/CPHQ/CCMC/ CMSA certifications (preferred)

Tools

Microsoft Office

Job description

Molina Healthcare in the United States seeks a physician leader to provide medical oversight and expertise in appropriateness and medical necessity of services for plan members, with a focus on improving efficiency, patient satisfaction and care quality in the most effective setting.

You will support utilization management programs, lead clinical quality improvement, participate in NCQA/URAC compliance, educate networks and medical staff, and ensure care delivery meets regulatory standards