Medical Director Job in Bothell 98011, Washington 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:
- Facilitate conformance to DHS, DMHC, NCQA and other regulatory requirements
- Review quality referred issues, focused reviews and recommends corrective actions
- Attend or chair committees such as Credentialing, PT,UM Ops, as directed by CMO
Provides medical leadership in UM departments:
- Evaluate authorization requests in timely support of nurse reviewers and manage the denial process
- Review cases with concurrent review nurses
- Provide medical expertise for care management
- Monitor appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care
- Conduct retrospective reviews of claims and appeals and resolve grievances related to medical quality of care
- Actively participate in the functioning of the plan grievance procedures
- Ensure that medical decisions are rendered by qualified medical personnel and are not influenced by fiscal or administrative management considerations
- Ensure that the medical 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 implement medical policies
- Directly involved in the implementation of Quality Improvement activities
Educate and interact with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management:
- Stabilize, improve and educate the PCP and Specialty networks
- Work with Contracting Department in contract negotiation
- Identify and resolve UM/QM issues of network practitioners
- Monitor practitioner practice patterns and recommends corrective action
- Foster Clinical Practice Guideline implementation and evidence-based medical practice
Interface with other MHC department i.e. Member Services, Provider Services, Claims and Contracting to coordinate operations and programs:
- Utilize 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, Medi-Cal, MediCare and Pharmacy benefit management
- Good Interpersonal communication skills, collaborative ability and ability to positively influence physicians
- 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.
- Good Interpersonal communication skills, collaborative ability and ability to positively influence physicians
- Basic knowledge of management practices, human relations, consensus building, and finance
- Excellent verbal and written technique. Must be professionally respected by peers
Knowledge of applicable state, federal and third party regulations
- Knowledge of WA 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
Molina Healthcare is an Equal Opportunity Employer M/F/D/V.
See Job Description
