Medical Director Job in Troy 48007, Michigan Us

MOLINA HEALTHCARE – MEDICAL DIRECTOR

 

POSITION SUMMARY

The Medical Director will provide medical professional judgment for and oversight of the Utilization Management Program to ensure that the healthcare and services provided to Plan members are medically necessary, appropriate, meets contractual compliance and community medical practice standards.

 

REQUIRED SKILLS AND QUALIFICATIONS

Education:

·         Required:  Doctorate degree in Medicine

·         Preferred:  Masters in Business Administration, Public Health, Healthcare Administration, etc.

 

Experience:

REQUIRED:

·         2-plus years previous Medical Director experience

·         2-plus years Utilization/ Quality Program Management

·         2-plus years HMO/Managed Care operations experience

·         5-plus years Clinical practice

·         Previous supervisory experience

·         Interqual competency

 

PREFERRED:

·      Prefer Peer Review, medical policy/procedure development, provider contracting experience

 

Licensure/Certification:

·         Valid Michigan Medical License (Must be free of sanctions from Medicaid or any other government program and without restrictions that would affect job performance)

·         Board Certification (Pediatrics, Family Practice, or Internal Medicine preferred)

·         Current Drug Enforcement Agency Certificate

 

PRINCIPLE ACCOUNTABILITIES

·         Responsible for clinical oversight of the Utilization Management Program. Provides leadership and participates in UM Dept. meetings as an active member of the UM team, to discuss prior authorization, inpatient concurrent review, discharge planning and case management issues. Promotes UM programs to meet all regulatory requirements.

·         Evaluates referrals from the UM Dept. staff which do not meet medical necessity and appropriateness criteria, and has final decision authority and accountability for approval or denial of payment for services. Contacts referring or attending physicians to discuss cases which do not meet medical necessity or appropriateness criteria. Functions as a liaison and educates the provider network regarding the UM Program, and assists in interpretation of policies, procedures, referral process, etc.

·         Address appeals from providers and members for medical necessity and appropriateness.

·         Assists the Chief Medical Officer with continuous Quality Improvement activities that help achieve NCQA accreditation. Evaluates quality and utilization related issues, and is responsible for referrals for quality reviews and prepares information for the PRC for further evaluation and resolution.

·         Responds to and serves as a resource to the UM Dept. staff regarding collection and interpretation of member medical record information.

·         Performs other duties as assigned.

·         Ensures that authorization decisions are rendered by qualified medical personnel, without hindrance due to fiscal or administrative incentives.

 

Additional Skills and Knowledge

·         Computer literacy (Microsoft Office Products)

·         Excellent verbal and written communication skills

·         Organization skills

·         Problem solving

·         Analytical ability

·         Communication skills

·         Interpersonal skills.

 

 

 

Molina Healthcare is an Equal Opportunity Employer M/F/D/V.