Medical Director Job in Albuquerque 87101, New Mexico US
MOLINA HEALTHCARE – MEDICAL DIRECTOR
POSITION SUMMARY
Provide medical oversight 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.
Duties and Responsibilities
Provides clinical support for all areas of Medical Affairs.
- Facilitates conformance to DHS, DMHC, NCQA and other regulatory requirements
- Reviews quality referred issues, focused reviews and recommends corrective actions
- Attends or chairs committees such as Credentialing, PT,UM Ops, as directed by CMO
- Provides medical leadership in UM departments:
- Evaluates authorization requests in timely support of nurse reviewers and manages the denial process.
- Reviews cases with concurrent review nurses.
- Provides medical expertise for care management
- Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.
- Conducts retrospective reviews of claims and appeals, and resolves grievances related to medical quality of care.
- Actively participates in the functioning of the plan grievance procedures.
- Ensures that medical decisions are rendered by qualified medical personnel, and are not influenced by fiscal or administrative management considerations.
- Ensures that the medical 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 medical policies.
- Directly involved in the implementation of Quality Improvement activities.
- Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management:
- Stabilizes, improves and educates the PCP and Specialty networks.
- Works with Contracting Department in contract negotiation.
- Identifies and resolves UM/QM issues of network practitioners.
- Monitors practitioner practice patterns and recommends corrective action
- Fosters Clinical Practice Guideline implementation and evidence-based medical practice
- Interfaces with other MHC department i.e. Member Services, Provider Services, Claims and Contracting to coordinate operations and programs.
- Utilizes IT and data analysts to produce tools used to report, monitor and improve Utilization Management
- Participate in regulatory, professional and community activities to provide MHC input and become knowledgeable regarding regulatory, professional and community standards and issues
Knowledge, Skills and Abilities
- Knowledge of 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, evidence-based guidelines, and current clinical knowledge.
- Basic knowledge of management practices, human relations, consensus building, and finance.
- Good Interpersonal communication skills, collaborative ability and ability to positively influence physicians
- Excellent verbal and written technique. Must be professionally respected by peers.
- Knowledge of applicable state, federal and third party regulations.
- Physical capacity and personal transportation availability to commute to and from corporate offices, Staff Model Offices, and provider offices and facilities.
- Excellent verbal and written communication skills
- Ability to abide by Molina’s policies
- Ability to maintain attendance to support required quality and quantity of work
- Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
- Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers
REQUIRED SKILLS AND QUALIFICATIONS
Education:
Required: Doctorate Degree in Medicine
Preferred: Board Certified (primary care preferred)
Experience:
Required:
- 2 years previous Medical Director
- 3 years Utilization/Quality Program Management
- Minimum 5 years clinical practice.
- Minimum 2 years HMO/Managed Care.
Preferred:
Prefer Peer Review, medical policy/procedure development, provider contracting experience
Required Licensure/Certification:
A current New Mexico Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare.
Molina Healthcare is an Equal Opportunity Employer M/F/D/V.
See Job Description
