Medical Director (Wi)

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

Job summary

Molina Healthcare is seeking a Medical Director to oversee the appropriateness and medical necessity of services for plan members, aiming to improve efficiency and satisfaction for members and providers while ensuring care in the most effective setting. You will influence strategy for quality and cost-effective member care in a complex network.

The role involves leading utilization management activities, coordinating with clinical leadership, and guiding NCQA/URAC accreditation efforts, with a

Qualifications

• At least 3 years health care experience, including at least 2 years of medical practice.
• Active and unrestricted MD or 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.

Responsibilities

• Provides medical oversight and expertise in appropriateness and medical necessity of services.
• Supports utilization management programs and action plans for high-quality member care.
• Evaluates effectiveness of utilization management practices and monitors utilization.
• Educates network providers and medical managers on utilization practices and resource management.
• Leads knowledge, implementation, training, and supervision of medical necessity criteria.
• Participates in and maintains the integrity of the appeals process.
• Investigates adverse incidents and quality of care concerns.
• Prepares for NCQA and URAC certifications.
• Provides leadership for NCQA standards and quality improvement activities.
• Ensures conformance to Medicare, Medicaid, NCQA and other regulations.
• Reviews quality issues and recommends corrective actions.
• Conducts retrospective reviews and resolves grievances related to quality of care.
• Chairs committees like credentialing and P&T as required.
• Evaluates authorization requests and manages denial processes.
• Monitors care across hospitals, SNFs, and home care for quality and cost-efficiency.
• Ensures medical decisions are rendered by qualified personnel.
• Ensures medical protocols and conduct rules are followed.
• Develops and implements plan medical policies.
• Supports implementation of quality improvement activities.
• Stabilizes and educates PCPs and specialty networks; monitors practice patterns.
• Fosters guideline implementation and evidence-based practices.
• Uses data analytics to report and improve utilization management.
• Participates in regulatory, professional and community activities.

Skills

Cross-functional collaboration

Communication skills

Organizational skills

Critical thinking

Problem-solving

Attention to detail

Education

MD/DO license in state of practice

Board certification

Tools

MS Office

Job description

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.