Molina Healthcare
Overview
Job Description: Responsible for serving as the primary liaison between administration and medical staff. Ensures the ongoing development and implementation of policies and procedures that guide and support the provisions of medical staff services. Maintains working knowledge of applicable national, state, and local laws and regulatory requirements affecting the medical and clinical staff.
Responsibilities
Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, and meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization, and effective resource management.
Develops and implements a Utilization Management program and action plan, including strategies to ensure high quality patient care and the most appropriate care setting. Evaluates UM effectiveness. Actively monitors for over- and under-utilization. Leads in knowledge, implementation, training, and supervision of the use of criteria for medical necessity.
Maintains the integrity of the appeals process, investigates adverse incidents and quality-of-care concerns, participates in preparation for NCQA and URAC certifications, and develops NCQA-compliant clinical quality improvement activity in collaboration with the clinical lead, medical director, and quality improvement staff.
Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.
Reviews quality-referred issues, conducts focused reviews, and recommends corrective actions.
Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.
Attends or chairs committees as required (e.g., Credentialing, P&T) as directed by the Chief Medical Officer.
Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process.
Monitors care and services across the continuum (hospitals, skilled nursing facilities, home care) to ensure quality, cost-efficiency, and continuity of care.
Ensures medical decisions are rendered by qualified medical personnel and meet standards for acceptable medical care, without inappropriate influence from fiscal or administrative management.
Ensures that medical protocols and conduct rules for plan medical personnel are followed and that plan medical policies are developed and implemented.
Provides implementation support for Quality Improvement activities.
Educates and stabilizes the Primary Care Physician and Specialty networks; monitors practitioner practice patterns and recommends corrective actions when needed.
Fosters Clinical Practice Guideline implementation and evidence-based medical practice.
Utilizes IT and data analysts to produce tools to report, monitor, and improve Utilization Management.
Participates in regulatory, professional and community activities.
Qualifications
Doctorate Degree in Medicine
Board Certified or eligible in a primary care specialty
3+ years relevant experience, including 2 years as a Medical Director in a clinical practice
Current clinical knowledge
Strong management and communication skills, consensus building, collaborative ability, and financial acumen
Knowledge of applicable state, federal and third party regulations
Current state medical license without restrictions to practice and free of sanctions from Medicaid or Medicare
Board Certification (Primary Care preferred)
Education and Certifications
Master’s in Business Administration, Public Health, Healthcare Administration, or related field
Peer Review, medical policy/procedure development, provider contracting experience
Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, group/IPA practice, capitation, HMO regulations, managed care systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines
Experience in Utilization/Quality Program management
HMO/Managed care experience
Physical Demands Working environment is generally favorable with adequate lighting and temperature. Office environment with minimal exposure to unpleasant and/or hazardous conditions. Ability to sit for long periods. Reasonable accommodations may be made for disabilities to perform essential functions.
Additional To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $161,914.25 - $315,733 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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Responsibilities
Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, and meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization, and effective resource management.
Develops and implements a Utilization Management program and action plan, including strategies to ensure high quality patient care and the most appropriate care setting. Evaluates UM effectiveness. Actively monitors for over- and under-utilization. Leads in knowledge, implementation, training, and supervision of the use of criteria for medical necessity.
Maintains the integrity of the appeals process, investigates adverse incidents and quality-of-care concerns, participates in preparation for NCQA and URAC certifications, and develops NCQA-compliant clinical quality improvement activity in collaboration with the clinical lead, medical director, and quality improvement staff.
Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.
Reviews quality-referred issues, conducts focused reviews, and recommends corrective actions.
Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.
Attends or chairs committees as required (e.g., Credentialing, P&T) as directed by the Chief Medical Officer.
Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process.
Monitors care and services across the continuum (hospitals, skilled nursing facilities, home care) to ensure quality, cost-efficiency, and continuity of care.
Ensures medical decisions are rendered by qualified medical personnel and meet standards for acceptable medical care, without inappropriate influence from fiscal or administrative management.
Ensures that medical protocols and conduct rules for plan medical personnel are followed and that plan medical policies are developed and implemented.
Provides implementation support for Quality Improvement activities.
Educates and stabilizes the Primary Care Physician and Specialty networks; monitors practitioner practice patterns and recommends corrective actions when needed.
Fosters Clinical Practice Guideline implementation and evidence-based medical practice.
Utilizes IT and data analysts to produce tools to report, monitor, and improve Utilization Management.
Participates in regulatory, professional and community activities.
Qualifications
Doctorate Degree in Medicine
Board Certified or eligible in a primary care specialty
3+ years relevant experience, including 2 years as a Medical Director in a clinical practice
Current clinical knowledge
Strong management and communication skills, consensus building, collaborative ability, and financial acumen
Knowledge of applicable state, federal and third party regulations
Current state medical license without restrictions to practice and free of sanctions from Medicaid or Medicare
Board Certification (Primary Care preferred)
Education and Certifications
Master’s in Business Administration, Public Health, Healthcare Administration, or related field
Peer Review, medical policy/procedure development, provider contracting experience
Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, group/IPA practice, capitation, HMO regulations, managed care systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines
Experience in Utilization/Quality Program management
HMO/Managed care experience
Physical Demands Working environment is generally favorable with adequate lighting and temperature. Office environment with minimal exposure to unpleasant and/or hazardous conditions. Ability to sit for long periods. Reasonable accommodations may be made for disabilities to perform essential functions.
Additional To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $161,914.25 - $315,733 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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