Idaho Staffing
Job Summary
Responsible for serving as the primary liaison between administration and medical staff. Assures the ongoing development and implementation of policies and procedures that guide and support the provisions of medical staff services. Maintains a working knowledge of applicable national, state, and local laws and regulatory requirements affecting the medical and clinical staff. Marketplace UM reviews. MD licenses required for the following states: WA, FL, MI, MS, NM, KY, TX, IL, OH, ID, SC, UT, WI, AZ, NV, IA, GA. Job Duties
Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members. Develops and implements a Utilization Management program and action plan. Participates in and maintains the integrity of the appeals process. Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements. Reviews quality referred issues, 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. Evaluates authorization requests in timely support of nurse reviewers. Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care. Ensures that medical decisions are rendered by qualified medical personnel. Ensures that medical protocols and rules of conduct for plan medical personnel are followed. Develops and implements plan medical policies. Provides implementation support for Quality Improvement activities. Stabilizes, improves and educates the Primary Care Physician and Specialty networks. 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. Actively participates in regulatory, professional and community activities. Job Qualifications
Required Education:
Doctorate Degree in Medicine. Board Certified or eligible in a primary care specialty. Required Experience/Knowledge, Skills & Abilities:
3+ years relevant experience, including: 2 years previous experience as a Medical Director in a clinical practice. Current clinical knowledge. Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen. Knowledge of applicable state, federal and third party regulations. Required License, Certification, Association:
Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. Preferred Education:
Master's in Business Administration, Public Health, Healthcare Administration, etc. Preferred Experience:
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 healthcare 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. Preferred License, Certification, Association:
Board Certification (Primary Care preferred). Physical Demands:
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. 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.
Responsible for serving as the primary liaison between administration and medical staff. Assures the ongoing development and implementation of policies and procedures that guide and support the provisions of medical staff services. Maintains a working knowledge of applicable national, state, and local laws and regulatory requirements affecting the medical and clinical staff. Marketplace UM reviews. MD licenses required for the following states: WA, FL, MI, MS, NM, KY, TX, IL, OH, ID, SC, UT, WI, AZ, NV, IA, GA. Job Duties
Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members. Develops and implements a Utilization Management program and action plan. Participates in and maintains the integrity of the appeals process. Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements. Reviews quality referred issues, 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. Evaluates authorization requests in timely support of nurse reviewers. Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care. Ensures that medical decisions are rendered by qualified medical personnel. Ensures that medical protocols and rules of conduct for plan medical personnel are followed. Develops and implements plan medical policies. Provides implementation support for Quality Improvement activities. Stabilizes, improves and educates the Primary Care Physician and Specialty networks. 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. Actively participates in regulatory, professional and community activities. Job Qualifications
Required Education:
Doctorate Degree in Medicine. Board Certified or eligible in a primary care specialty. Required Experience/Knowledge, Skills & Abilities:
3+ years relevant experience, including: 2 years previous experience as a Medical Director in a clinical practice. Current clinical knowledge. Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen. Knowledge of applicable state, federal and third party regulations. Required License, Certification, Association:
Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. Preferred Education:
Master's in Business Administration, Public Health, Healthcare Administration, etc. Preferred Experience:
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 healthcare 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. Preferred License, Certification, Association:
Board Certification (Primary Care preferred). Physical Demands:
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. 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.