Job Summary Bring your physician leadership and utilization review/management experience to our Medical Director role in the Illinois health plan. Solid performance in UM/UR arena may lead to project work in population health and affecting health outcomes for tens of thousands of members.
What you will do:
Provide medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to Plan 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.
• Facilitate conformance to Medicare, Medicaid, NCQA and other regulatory requirements.
• Review quality referred issues, focused reviews and recommends corrective actions.
• Conduct retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.
• Attend or chair committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer.
• Evaluate authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages 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, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.
• Ensure that medical protocols and rules of conduct for plan medical personnel are followed.
• Develop and implements plan medical policies.
• Provide implementation support for Quality Improvement activities.
• Stabilize, improve and educate the Primary Care Physician and Specialty networks. Monitor practitioner practice patterns and recommends corrective actions if needed.
• Work with Contracting Department in contract negotiation.
• Foster Clinical Practice Guideline implementation and evidence-based medical practice.
• Utilize IT and data analysts to produce tools to report, monitor and improve Utilization Management.
• Actively participate in regulatory, professional and community activities.
Job Qualifications Required Education Doctorate Degree in Medicine
7 - 9 years relevant experience, including:
• 5+ years clinical practice.
• Previous experience as a Medical Director conducting utilization reviews.
• 3 years experience in Utilization/Quality Program management.
• 2+ years HMO/Managed Care experience.
• 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
Current IL state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare.
• 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.
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.
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