Medicare Medical Director: Utilization & Quality Oversight

Molina Healthcare; United States; On-site; USD 180,000 - 240,000; Full time

Job summary

Molina Healthcare seeks a physician leader to provide medical oversight and ensure appropriateness and medical necessity of services for members, driving efficiency and satisfaction across providers and facilities.

You will contribute to strategy for high-quality, cost-effective member care, lead QA initiatives, and participate in regulatory accreditation processes within a large, matrixed healthcare organization.

Qualifications

• 3+ years health care experience including ≥2 years medical practice.
• Active and unrestricted MD or DO license in state of practice.
• Board certification.
• Knowledge of national, state, and local 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.
• MS Office proficiency and ability to learn new programs.

Responsibilities

• Determines appropriateness and medical necessity of health care services for plan members.
• Supports utilization management program and action plans for high-quality member care.
• Evaluates effectiveness of utilization management practices.
• Educates network providers on utilization practices and resource management.
• Leads knowledge and training on criteria for medical necessity.
• Participates in appeals processes and related activities.
• 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 and NCQA regulatory requirements.
• Reviews quality issues and recommends corrective actions.
• Conducts retrospective reviews of claims and appeals; resolves grievances.
• Chairs credentialing and Pharmacy & Therapeutics committees as required.
• Evaluates authorization requests to support nurse reviewers and manage denials.
• Monitors care continuity across hospitals, SNFs, and home care.
• Ensures medical decisions are by qualified personnel and meet standards.
• Ensures medical policies are implemented.
• Provides implementation support for quality improvement activities.
• Stabilizes and educates PCPs and specialty networks; monitors practice patterns.
• Fosters clinical guideline implementation and evidence-based practice.
• Utilizes IT and data analytics to report and improve utilization management.
• Participates in regulatory, professional and community activities.

Skills

Verbal and written communication

Critical thinking

Active listening

Decision making

Problem solving

Attention to detail

Organization and time management

Multi-tasking

Cross-functional collaboration

MS Office proficiency

Education

MD or DO license

Board certification

Healthcare certifications (CPHM/CPHQ/CCMC)

Tools

MS Office

Job description

Molina Healthcare seeks a physician leader to provide medical oversight and ensure appropriateness and medical necessity of services for members, driving efficiency and satisfaction across providers and facilities.

You will contribute to strategy for high-quality, cost-effective member care, lead QA initiatives, and participate in regulatory accreditation processes within a large, matrixed healthcare organization.