Medical Director (Wi)

Molina Healthcare; Kenosha (WI); Sur place; USD 186 000 - 363 000; Plein temps

Résumé du poste

Molina Healthcare in Wisconsin seeks a physician leader to oversee medical necessity determinations and utilization management, ensuring high-quality member care. This role collaborates with networks, medical managers, and leadership to implement evidence-based practices.

The position requires MD or DO licensure, board certification, and strong regulatory knowledge. Expect active participation in accreditation activities and quality improvement initiatives.

Qualifications

• Requires an MD or DO license in the practicing state.
• Board certification is required.
• Strong organizational and time-management skills.

Responsabilités

• Determines appropriateness and medical necessity of health care services.
• Supports utilization management programs and action plans for high-quality member care.
• Evaluates effectiveness of utilization management practices and monitors for over/under-utilization.
• Educates providers on utilization practices and resource management.
• Leads knowledge and implementation of medical necessity criteria.

Connaissances

Communication

Time management

Multi-tasking

Attention to detail

Critical thinking

Problem solving

Microsoft Office

Formation

MD/DO degree

Board certification

Outils

Microsoft Office

Description du poste

JOB DESCRIPTION Job Summary

Provides medical oversight and expertise in appropriateness and medical necessity of services provided to members, targeting improvements in efficiency and satisfaction for both members and providers and ensuring members receive the most appropriate care in the most effective setting. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Determines appropriateness and medical necessity of health care services provided to plan members.
• Supports plan utilization management program and accompanying action plan(s), which includes strategies to ensure high-quality member care - ensuring members receive the most appropriate care at the most effective setting.
• Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization.
• Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
• Assumes leadership relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity.
• Participates in and maintains the integrity of the appeals process, both internally and externally.
• Responsible for investigation of adverse incidents and quality of care concerns.
• Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications.
• Provides leadership and consultation for NCQA standards/guidelines for the plan including compliant clinical quality improvement activity (QIA) in collaboration with clinical leadership and quality improvement teams.
• Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.
• Reviews quality referred issues, focused reviews and recommends corrective actions.
• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.
• Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and other committees as directed by the chief medical officer.
• Evaluates authorization requests in timely support of nurse reviewers, reviews cases requiring concurrent review and manages the denial process.
• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care.
• Ensures that medical decisions are rendered by qualified medical personnel and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care.
• Ensures medical protocols and rules of conduct for plan medical personnel are followed.
• Develops and implements plan medical policies.
• Provides implementation support for quality improvement activities.
• Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed.
• Fosters clinical practice guideline implementation and evidence-based medical practices.
• Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management.
• Actively participates in regulatory, professional and community activities.

Required Qualifications

• At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience.
• Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice.
• Board certification.
• Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff.
• Ability to work cross-collaboratively within a highly matrixed organization.
• Strong organizational and time-management skills.
• Ability to multi-task and meet deadlines.
• Attention to detail.
• Critical-thinking and active listening skills.
• Decision-making and problem-solving skills.
• Strong verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs.

Preferred Qualifications

• Experience with utilization/quality program management.
• Managed care experience.
• Peer review experience.
• Certified Professional in Healthcare Management (CPHM), Certified Professional in Health Care Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other health care or management certification.

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Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $186,201.39 - $363,093 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.