Medicare Medical Director: Utilization & Quality Oversight

Molina Healthcare; Northern (KY); Hybrid; USD 186,000 - 363,000; Full time

Job summary

Molina Healthcare is seeking a Medical Director to oversee medical necessity determinations and utilization management for plan members, ensuring high-quality, cost-effective care across networks and settings.

Responsibilities include leading clinical policy development, coordinating with providers and network managers, and guiding NCQA/URAC accreditation readiness while maintaining regulatory standards and member satisfaction.

Qualifications

• Minimum 3 years healthcare experience, including at least 2 years medical practice.
• Active and unrestricted MD or DO license in state of practice.
• Board certification required.
• Knowledge of Medicare/Medicaid, NCQA/URAC standards.
• Strong communication and organizational skills.

Responsibilities

• Determines medical necessity and appropriateness of services for plan members.
• Oversees utilization management programs and action plans.
• Monitors for over- and under-utilization and reports findings.
• Educates network providers on utilization practices and guidelines.
• Leads committees and supports NCQA/URAC accreditation efforts.

Skills

MD/DO license

Board certification

Regulatory knowledge

Cross-functional collaboration

Analytical skills

Quality improvement

Education

MD/DO degree

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a Medical Director to oversee medical necessity determinations and utilization management for plan members, ensuring high-quality, cost-effective care across networks and settings.

Responsibilities include leading clinical policy development, coordinating with providers and network managers, and guiding NCQA/URAC accreditation readiness while maintaining regulatory standards and member satisfaction.