Medical Director for Medicare Services

Overview Job Summary We are seeking a dedicated Medical Director to provide expert medical oversight and guidance on service appropriateness and medical necessity for our members. This role is crucial in enhancing the efficiency and satisfaction of our healthcare services while ensuring that members receive optimal care in the best setting possible. You will play a key role in shaping strategies to deliver high-quality, cost-effective healthcare. Responsibilities Determine the appropriateness and medical necessity of services delivered to plan members. Support and enhance the plan's utilization management program, ensuring high-quality care for members. Evaluate the effectiveness of utilization management practices, and monitor for both over- and under-utilization of services. Educate and collaborate with network providers and medical managers on best practices in utilization and resource management. Lead and supervise the implementation of medical necessity criteria and associated training. Participate in the appeals process to maintain integrity and transparency. Investigate adverse incidents and address quality of care concerns effectively. Play a significant role in achieving and maintaining NCQA and URAC certifications. Provide leadership and consultation on NCQA standards, ensuring compliant quality improvement activities. Facilitate adherence to Medicare, Medicaid, NCQA, and other regulatory standards. Review quality-related issues and recommend necessary corrective actions. Conduct retrospective reviews of claims and appeals, resolving grievances concerning medical quality. Attend and potentially chair committees such as credentialing and Pharmacy and Therapeutics (P&T). Evaluate authorization requests promptly to support nursing reviews and manage denial processes. Ensure monitoring of care services across various facilities to maintain quality and cost-efficiency. Guarantee that medical decisions are made by qualified personnel, ensuring adherence to medical care standards. Develop and implement medical policies for the plan. Support initiatives for quality improvement activities. Assist primary care physicians and specialty networks in improving and stabilizing practices. Encourage the implementation of clinical practice guidelines and evidence-based medicine. Utilize data analytics and information technology to enhance utilization management reporting. Engage actively in regulatory, professional, and community endeavors. Required Qualifications A minimum of 3 years of healthcare experience, including at least 2 years in medical practice, or relevant educational background. Active and unrestricted MD or DO license in the state where you will be practicing. Board certification in your medical specialty. Familiarity with national, state, and local regulatory requirements affecting clinical staff. Ability to collaborate effectively within a complex organizational structure. Strong organizational and time management skills, with the ability to multitask and meet deadlines. Detail-oriented with excellent critical-thinking and active listening abilities. Proficient in decision-making and problem-solving. Exceptional verbal and written communication skills. Proficiency in Microsoft Office Suite and a willingness to learn new software. Preferred Qualifications Experience in utilization management or quality program management. Background in managed care. Experience with peer review processes. Certifications such as CPHM, CPHQ, CCMC, CMSA, or similar. Additional Information If you are a current Molina employee interested in this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package, and is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $161,914.25 - $315,733 / ANNUAL *Actual compensation may differ based on geographic location, work experience, education, and skill level.