Medical Director, Utilization & Quality Improvement

Molina Healthcare; San Bernardino (CA); On-site; USD 186,000 - 363,000; Full time

Job summary

Molina Healthcare in California seeks an experienced physician leader to oversee medical necessity decisions and utilization management for our members. You will guide clinical policy, ensure appropriate care settings, and support NCQA/URAC preparations.

This full-time role requires strong collaboration across networks, regulatory knowledge, and a track record in quality improvement and patient safety.

Qualifications

• At least 3 years health care experience, including 2 years of medical practice.
• Active and unrestricted MD or DO license in state of practice.
• Board certification is required.
• Working knowledge of national, state, and local health care regulations.
• Ability to collaborate across a highly matrixed organization.

Responsibilities

• Determine appropriateness and medical necessity of health care services for plan members.
• Support utilization management programs and action plans to ensure quality and cost-effectiveness.
• Educate providers and medical managers on utilization practices and guidelines.
• Lead and supervise use of medical necessity criteria and QA activities.
• Participate in NCQA/URAC certifications and regulatory compliance reviews.
• Review and adjudicate appeals, adverse events, and quality concerns.
• Facilitate committees such as credentialing and P&T as directed by leadership.

Skills

Clinical leadership

Utilization management

Regulatory knowledge

Communication

Analytical thinking

Education

MD or DO

Board certification

Tools

MS Office

Job description

Molina Healthcare in California seeks an experienced physician leader to oversee medical necessity decisions and utilization management for our members. You will guide clinical policy, ensure appropriate care settings, and support NCQA/URAC preparations.

This full-time role requires strong collaboration across networks, regulatory knowledge, and a track record in quality improvement and patient safety.