Senior Medical Director, Quality & Utilization

Molina Healthcare; Waukesha (WI); Presencial; USD 186.000 - 363.000; Jornada completa

Descripción de la vacante

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

Formación

• 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.

Responsabilidades

• 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.

Conocimientos

Cross-functional collaboration

Communication skills

Organizational skills

Critical thinking

Problem-solving

Attention to detail

Educación

MD/DO license in state of practice

Board certification

Herramientas

MS Office

Descripción del empleo

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