Medical Director (Based in MI)

Molina Healthcare•Long Beach, CA

About The Position

Provides medical oversight and expertise in determining the appropriateness and medical necessity of services provided to plan members. The role aims to improve efficiency and satisfaction for members and providers, ensure members receive appropriate care in effective settings, and contribute to the strategy for delivering quality, cost-effective care. The Medical Director supports utilization management, quality improvement, appeals, regulatory compliance, medical policy development, and oversight of care across hospitals, skilled nursing facilities, and home care. The role collaborates with clinical leaders, providers, medical managers, quality teams, and committees, and uses information technology and data analytics to monitor and improve utilization management.

Requirements

At least 3 years of health care experience, including at least 2 years of medical practice experience, or an equivalent combination of relevant education and experience.
Active and unrestricted MD or DO license in the 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 collaboratively across a highly matrixed organization.
Strong organizational and time-management skills.
Ability to multitask and meet deadlines.
Attention to detail.
Critical-thinking and active-listening skills.
Decision-making and problem-solving skills.
Strong verbal and written communication skills.
Proficiency with Microsoft Office and applicable software programs, and ability to learn new programs.

Nice To Haves

Experience with utilization or 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 another health care or management certification.

Responsibilities

Determine the appropriateness and medical necessity of health care services provided to plan members.
Support the plan utilization management program and action plans to promote high-quality care in the most effective setting.
Evaluate utilization management practices and monitor for over- and under-utilization.
Educate and interact with network and group providers and medical managers about utilization practices, guidelines, pharmacy utilization, and resource management.
Lead knowledge, implementation, training, and supervision related to medical necessity criteria.
Participate in and maintain the integrity of internal and external appeals processes.
Investigate adverse incidents and quality-of-care concerns.
Participate in preparation for NCQA and URAC certifications.
Provide leadership and consultation on NCQA standards and guidelines, including compliant clinical quality improvement activities in collaboration with clinical leadership and quality improvement teams.
Facilitate conformance with Medicare, Medicaid, NCQA, and other regulatory requirements.
Review quality-referred issues and focused reviews, and recommend corrective actions.
Conduct retrospective reviews of claims and appeals and resolve grievances related to medical quality of care.
Attend or chair committees as required, including credentialing and Pharmacy and Therapeutics committees, as directed by the chief medical officer.
Evaluate authorization requests in support of nurse reviewers, review cases requiring concurrent review, and manage the denial process.
Monitor care and services across hospitals, skilled nursing facilities, and home care to promote quality, cost-efficiency, and continuity of care.
Ensure medical decisions are made by qualified medical personnel, are not influenced by fiscal or administrative considerations, and meet standards for acceptable medical care.
Ensure plan medical personnel follow medical protocols and rules of conduct.
Develop and implement plan medical policies.
Support implementation of quality improvement activities.
Stabilize, improve, and educate primary care physicians and specialty networks; monitor practitioner practice patterns and recommend corrective actions as needed.
Promote clinical practice guideline implementation and evidence-based medical practices.
Use information technology and data analytics to develop tools for reporting, monitoring, and improving utilization management.
Participate in regulatory, professional, and community activities.