Medical Director (New Mexico)

divh2Job Title/h2pProvides medical oversight and expertise in 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./ppEssential Job Duties:/pulliDetermines appropriateness and medical necessity of health care services provided to plan members./liliSupports plan utilization management program and accompanying action plan(s), which includes strategies to ensure high-quality member care - ensuring members receive the most appropriate care at the most effective setting./liliEvaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization./liliEducates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management./liliAssumes leadership relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity./liliParticipates in and maintains the integrity of the appeals process, both internally and externally./liliResponsible for investigation of adverse incidents and quality of care concerns./liliParticipates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications./liliProvides 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./liliFacilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements./liliReviews quality referred issues, focused reviews and recommends corrective actions./liliConducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care./liliAttends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (PT) and other committees as directed by the chief medical officer./liliEvaluates authorization requests in timely support of nurse reviewers, reviews cases requiring concurrent review and manages the denial process./liliMonitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care./liliEnsures 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./liliEnsures medical protocols and rules of conduct for plan medical personnel are followed./liliDevelops and implements plan medical policies./liliProvides implementation support for quality improvement activities./liliStabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed./liliFosters clinical practice guideline implementation and evidence-based medical practices./liliUtilizes information technology and data analytics to produce tools to report, monitor and improve utilization management./liliActively participates in regulatory, professional and community activities./li/ulpRequired Qualifications:/pulliAt least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience./liliActive and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice (New Mexico)./liliBoard certification./liliWorking knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff./liliAbility to work cross-collaboratively within a highly matrixed organization./liliStrong organizational and time-management skills./liliAbility to multi-task and meet deadlines./liliAttention to detail./liliCritical-thinking and active listening skills./liliDecision-making and problem-solving skills./liliStrong verbal and written communication skills./liliMicrosoft Office suite/applicable software program(s) proficiency, and ability to learn new programs./li/ulpPreferred Qualifications:/pulliExperience with utilization/quality program management./liliManaged care experience./liliPeer review experience./liliCertified Professional in Healthcare Management (CPHM), Certified Professional in Health Care Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other health care or management certification./li/ulpTo all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V./ppPay Range: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level./p/div