Senior Medical Director (Based in IA)

Molina Healthcare•Long Beach, IA

21d

About The Position

The Senior Medical Director provides subject matter expertise and leadership for health plan or shared-services advanced clinical managed care and clinical performance. The role applies specialty expertise, such as transplant or genetics, to support prior authorization, inpatient concurrent review, discharge planning, clinical care management, and interdisciplinary care team activities. The position may lead medical directors and provide oversight and expertise regarding the appropriateness and medical necessity of services, helping ensure members receive appropriate care in effective settings. It contributes to the strategy for delivering quality, cost-effective member care.

Requirements

At least 10 years of relevant experience, including clinical practice experience, and at least 2 years as a medical director in a managed care setting supporting utilization management or quality management initiatives, or an equivalent combination of relevant education and experience.
At least 5 years of management or leadership experience.
MD or DO degree.
Active, unrestricted 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.
Demonstrated ability to make strategic decisions.
Knowledge of health care regulatory and legislative processes, including ability to read and interpret legislation.
Business and financial acumen.
Competency in evidence-based clinical criteria.
Experience in peer review, medical policy and procedure development, and provider contracting.
Experience influencing and gaining consensus across stakeholders.
Ability to work collaboratively across a highly matrixed organization.
Excellent verbal and written communication skills.
Proficiency with Microsoft Office or applicable software programs and electronic medical records (EMR).

Nice To Haves

Certification such as 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 another health care or management certification.

Responsibilities

Apply advanced clinical expertise to prior authorization, inpatient concurrent review, discharge planning, care management, and interdisciplinary care team activities.
Ensure authorization decisions are made by qualified medical personnel and are not hindered by fiscal or administrative incentives.
Analyze data to identify medical cost-saving and quality-improvement opportunities.
Account for regulatory and accreditation performance of the assigned team and respond to inquiries, issues, and complaints from government and accreditation regulators.
Develop medical policies and procedures as needed.
Conduct peer review processes.
As applicable, lead medical directors responsible for assessing the appropriateness and medical necessity of health care services provided to plan members.
As applicable, hire, train, develop, and manage the team, with accountability for team performance and department-specific goals.
As applicable, develop and sustain a high-performance team focused on best-in-class solutions, attracting, developing, and retaining talent in support of strategy and long-term business objectives.
Contribute to the strategy for quality and cost-effective member care.