Senior Medical Director (Medicare)

Molina Healthcare•Long Beach, CA

About The Position

Uses leadership and/or equivalent specialty expertise (transplant, genetics, etc.) to provide advanced clinical managed care / clinical performance. May lead and manage a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - ensuring members receive the most appropriate care in the most effective setting. Contributes to overarching strategy to provide quality and cost-effective member care.

Requirements

At least 8 years of relevant experience, including clinical practice experience, and at least 2 years as a medical director in managed care setting supporting utilization management/quality management initiatives, or equivalent combination of relevant education and experience.
Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice.
Board Certification.
Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff.
Demonstrated ability to make strategic decisions.
Knowledge of health care regulatory and legislative processes, including ability to read and interpret legislation.
Experience gaining consensus and collaborating in a highly matrixed organization.
Experience demonstrating strong leadership, communication, consensus building, collaboration and financial acumen abilities.
Evidence-based clinical criteria competency.
Peer review, medical policy/procedure development, and provider contracting experience.
Strong verbal and written communication skills.
Microsoft Office suite/applicable software program(s) proficiency.

Nice To Haves

At least 3 years management/leadership experience.
Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other Health care or management certification.

Responsibilities

Provides leadership and expertise in advanced clinical performance of prior authorization, inpatient concurrent review, discharge planning, care management and interdisciplinary care team (ICT) activities.
May lead a team of medical directors responsible for assessing appropriateness and medical necessity of health care services provided to plan members.
Recruits, hires, trains, mentors and develops medical director staff as needed.
Ensures that authorization decisions are rendered by qualified medical personnel and without hindrance due to fiscal or administrative incentives.
Analyzes data and identifies medical cost-savings and quality improvement opportunities.
Accounts for regulatory and accreditation performance of assigned team and responds to inquiries, issues and complaints from government and accreditation regulators.
Develops medical policies and procedures as needed.
Conducts peer review processes.