Medical Director (REMOTE in Iowa)
Company: Molina Healthcare
Location: Council Bluffs
Posted on: January 18, 2023
Job Description:
JOB DESCRIPTION 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. - KNOWLEDGE/SKILLS/ABILITIES
- 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, as well as 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, which includes strategies that ensure a high quality
of patient care, ensuring that patients receive the most
appropriate care at the most effective setting. - Evaluates the
effectiveness of UM practices. Actively monitors for over and
under-utilization. - Assumes a leadership position relative to
knowledge, implementation, training, and supervision of the use of
the criteria for medical necessity.
- Participates in and maintains the integrity of the appeals
process, both internally and externally. - - Responsible for the
investigation of adverse incidents and quality of care concerns. -
Participates in preparation for NCQA and URAC certifications. -
Develops and provides leadership for NCQA-compliant clinical
quality improvement activity (QIA) in collaboration with the
clinical lead, the medical director, and quality improvement
staff.
- 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 such as Credentialing,
P&T and others 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 appropriate care and
services through continuum among hospitals, skilled nursing
facilities and home care to ensure quality, cost-efficiency, and
continuity of care. --- - - - -Ensures that medical decisions are
rendered by qualified medical personnel, not influenced by fiscal
or administrative management considerations, and that the care
provided meets the standards for acceptable medical care. --- - - -
-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. -
Monitors practitioner practice patterns and recommends corrective
actions if 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. --- - - - -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: 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 Iowa -
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 -
$315,732.79 a year* *Actual compensation may vary from posting
based on geographic location, work experience, education and/or
skill level.
Keywords: Molina Healthcare, Council Bluffs , Medical Director (REMOTE in Iowa), Executive , Council Bluffs, Iowa
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