Medical Director (Medicare) - Full-time

Position Overview

Provides medical oversight and expertise in appropriateness and medical necessity of services provided to members, targeting improvements in efficiency and satisfaction for both members and providers and ensuring members receive the most appropriate care in the most effective setting. Contributes to overarching strategy to provide quality and cost-effective member care.

Key Responsibilities

• Determines appropriateness and medical necessity of health care services provided to plan members.
• Supports plan utilization management program and accompanying action plans to ensure high-quality member care in the most effective setting.
• Evaluates effectiveness of utilization management (UM) practices by actively monitoring for over and under-utilization.
• Educates and interacts with network, group providers, and medical managers regarding utilization practices, guideline usage, pharmacy utilization, and effective resource management.
• Assumes leadership in knowledge, implementation, training, and supervision regarding the use of criteria for medical necessity.
• Participates in and maintains the integrity of the appeals process, both internally and externally.
• Investigates adverse incidents and quality of care concerns.
• Participates in preparation for NCQA and URAC certifications.
• Provides leadership and consultation for NCQA standards/guidelines and compliant clinical quality improvement activities in collaboration with clinical leadership and quality improvement teams.
• 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 while resolving grievances related to medical quality of care.
• Attends or chairs committees, such as credentialing and Pharmacy & Therapeutics (P&T), as directed by the chief medical officer.
• Evaluates authorization requests, supports nurse reviewers with concurrent cases, and manages the denial process.
• Monitors the continuum of care across hospitals, skilled nursing facilities, and home care to ensure quality, cost-efficiency, and continuity of care.
• Ensures medical decisions are rendered by qualified personnel without undue influence from fiscal or administrative considerations.
• Ensures adherence to medical protocols and rules of conduct for plan medical personnel.
• Develops and implements plan medical policies.
• Provides support for quality improvement activities.
• Stabilizes, improves, and educates primary care physicians and specialty networks while monitoring practice patterns and recommending corrective actions as needed.
• Fosters clinical practice guideline implementation and evidence-based medical practices.
• Utilizes information technology and data analytics to create tools for reporting, monitoring, and improving utilization management.
• Actively participates in regulatory, professional, and community activities.

Required Qualifications

• At least 3 years of healthcare experience, including a minimum of 2 years in medical practice, or an equivalent combination of relevant education and experience.
• Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in the state of practice.
• Board certification.
• Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff.
• Ability to work cross-collaboratively within a highly matrixed organization.
• Strong organizational and time-management skills with the ability to multi-task and meet deadlines.
• Attention to detail, critical-thinking, active listening, decision-making, and problem-solving skills.
• Strong verbal and written communication skills.
• Proficiency in Microsoft Office suite and related software, with an aptitude for learning new programs.

Preferred Qualifications

• Experience with utilization/quality program management.
• Managed care experience.
• Peer review experience.
• Certification such as Certified Professional in Healthcare Management (CPHM), Certified Professional in Health Care Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA), or another healthcare/management credential.

Benefits & Perks

• Competitive benefits and compensation package
• Pay Range: $186,201.39 - $363,093 / ANNUAL
• Actual compensation may vary based on geographic location, work experience, education, and/or skill level.
• If you are a current Molina employee, please apply through the Internal Job Board.