Medical Director (WI)

Molina Healthcare Inc; Wisconsin; On-site; USD 180,000 - 240,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare Inc. is seeking a Medical Director to provide medical oversight for appropriateness and medical necessity of services delivered to plan members, with a focus on cost-effectiveness and quality outcomes.

The role will lead utilization management activities, collaborate with providers and clinical leadership, and drive NCQA and URAC accreditation preparation while ensuring compliance with Medicare/Medicaid standards.

Qualifications

• Active and unrestricted MD/DO license in state of practice.
• Board certification in a relevant medical field.
• Strong understanding of national, state, and local regulations affecting medical staff.
• Excellent verbal and written communication skills.
• Solid organizational and time-management abilities.
• Ability to multi-task and meet deadlines.
• High attention to detail and analytical thinking.
• Strong problem-solving and decision-making abilities.
• Proficiency with Microsoft Office applications.

Responsibilities

• Determines appropriateness and medical necessity of health care services for plan members.
• Supports utilization management programs and related action plans.
• Educates and interacts with providers and medical managers on utilization practices.
• Leads and mentors on use of medical necessity criteria.
• Participates in and maintains integrity of appeals processes.
• Reviews quality issues and recommends corrective actions.
• Participates in NCQA and URAC accreditation preparations.

Skills

MD/DO license

Board certification

Regulatory knowledge

Communication skills

Time management

Multi-tasking

Attention to detail

Critical thinking

Problem solving

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.
• To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

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