Leads and manages a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - ensuring members receive the most appropriate care in the most effective setting. Contributes to overarching strategy to provide quality and cost-effective member care.
Position is based in California.
Essential Job Duties
• Leads a team of medical directors responsible for assessing appropriateness and medical necessity of health care services provided to plan members.
• Provides leadership and expertise in performance of prior authorization, inpatient concurrent review, discharge planning, care management and interdisciplinary care team (ICT) activities.
• Recruits, hires, trains, mentors and develops medical director staff as needed.
• Ensures that authorization decisions are rendered by qualified medical personnel and without hindrance due to fiscal or administrative incentives.
• Analyzes data and identifies medical cost-savings and quality improvement opportunities.
• Accounts for regulatory and accreditation performance of assigned team and responds to inquiries, issues and complaints from government and accreditation regulators.
• Develops medical policies and procedures as needed.
• Conducts peer review processes.
Required Qualifications
• At least 8 years of relevant experience, including clinical practice experience, and at least 2 years as a medical director in managed care setting supporting utilization management/quality management initiatives, or equivalent combination of relevant education and experience.
• At least 3 years management/leadership experience.
• Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in 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.
• Experience gaining consensus, and collaborating in a highly matrixed organization.
• Experience demonstrating strong leadership, communication, consensus building, collaboration and financial acumen abilities.
• Evidence-based clinical criteria competency.
• Peer review, medical policy/procedure development, and provider contracting experience.
• Strong verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
• 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 other Health care or management certification.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Molina Healthcare is a FORTUNE 500 company that is focused exclusively on government-sponsored health care programs for families and individuals who qualify for government sponsored health care.
Molina Healthcare contracts with state governments and serves as a health plan providing a wide range of quality health care services to families and individuals. Molina Healthcare offers health plans in Arizona, California, Florida, Idaho, Illinois, Kentucky, Massachusetts, Michigan, Mississippi, Nevada, New Mexico, New York, Ohio, South Carolina, Texas, Utah, Virginia, Washington and Wisconsin. Molina also offers a Medicare product and has been selected in several states to participate in duals demonstration projects to manage the care for those eligible for both Medicaid and Medicare.
