Medical Director (Southern CA)

Job Description

Provides medical oversight and expertise in the 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.

Experience conducting Medi‑cal reviews.

Essential Job Duties

• Determine the appropriateness and medical necessity of health care services provided to plan members.
• Support the plan utilization management program and its action plan(s), implementing strategies to ensure high‑quality member care, and ensuring members receive the most appropriate care at the most effective setting.
• Evaluate the effectiveness of utilization management (UM) practices, actively monitoring for over‑ and under‑utilization.
• Educate and interact with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
• Assume leadership regarding knowledge, implementation, training and supervision of the use of the criteria for medical necessity.
• Participate in and maintain the integrity of the appeals process, both internally and externally.
• Investigate adverse incidents and quality of care concerns.
• Participate in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications.
• Provide leadership and consultation for NCQA standards / guidelines for the plan, including compliant clinical quality improvement activity (QIA) in collaboration with clinical leadership and quality improvement teams.
• Facilitate conformance to Medicare, Medicaid, NCQA and other regulatory requirements.
• Review quality referred issues, focused reviews and recommend corrective actions.
• Conduct retrospective reviews of claims and appeals and resolve grievances related to medical quality of care.
• Attend or chair committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and other committees as directed by the chief medical officer.
• Evaluate authorization requests in a timely manner to support nurse reviewers, review cases requiring concurrent review and manage the denial process.
• Monitor appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost‑efficiency, and continuity of care.
• Ensure that medical decisions are rendered by qualified medical personnel and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care.
• Ensure medical protocols and rules of conduct for plan medical personnel are followed.
• Develop and implement plan medical policies.
• Provide implementation support for quality improvement activities.
• Stabilize, improve and educate primary care physicians and specialty networks; monitor practitioner practice patterns and recommend corrective actions as needed.
• Foster clinical practice guideline implementation and evidence‑based medical practices.
• Utilize information technology and data analytics to produce tools to report, monitor and improve utilization management.
• Actively participate in regulatory, professional and community activities.

Required Qualifications

Preferred Qualifications

Pay Range

$161,914.25 – $315,733 / ANNUAL

Molina Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V

#J-18808-Ljbffr