Medical Director for Medicare Programs

Job Summary As a Medical Director for Medicare Programs, you will provide essential medical oversight and expertise aimed at improving the appropriateness and medical necessity of services rendered to our members. Your efforts will focus on enhancing efficiency and member satisfaction, ensuring that members receive the care they need in the most effective settings. You will play a pivotal role in our strategy to deliver high-quality, cost-effective care. Essential Job Duties Determine the appropriateness and medical necessity of healthcare services for plan members. Support the plan’s utilization management program, developing strategies to ensure high-quality member care and monitor over and under-utilization. Educate and engage with network providers and medical managers on utilization practices, guideline usage, pharmacy utilization, and effective resource management. Lead the implementation, training, and supervision of medical necessity criteria across the organization. Participate in the integrity and operation of the appeals process, both internally and externally. Investigate adverse incidents and address quality of care concerns. Prepare for NCQA and URAC certifications, ensuring compliance with national standards. Review quality referrals, conduct focused reviews, and recommend corrective actions. Conduct retrospective reviews of claims and appeals, resolving grievances regarding medical quality of care. Attend or chair relevant committees such as credentialing and Pharmacy and Therapeutics (P&T) committees. Evaluate authorization requests promptly to assist nurse reviewers while managing the denial process effectively. Monitor quality and service provision across hospitals, skilled nursing facilities, and home care to ensure care continuity and cost-efficiency. Guarantee that medical decisions are made by qualified professionals, free from administrative or fiscal influences. Ensure adherence to medical protocols and the rules of conduct for plan medical personnel. Develop and implement medical policies for the plan. Support quality improvement activities through effective implementation. Enhance primary care physicians and specialty networks, monitoring practice patterns and recommending corrective measures. Promote clinical practice guideline implementation and evidence-based practices. Utilize information technology and data analytics to create tools for monitoring and improving utilization management. Engage actively in regulatory, professional, and community activities. Required Qualifications Minimum of 3 years of healthcare experience, including at least 2 years of direct medical practice. Valid and unrestricted MD or DO license in the state of practice. Board certification. Comprehensive knowledge of relevant national, state, and local laws and regulations. Ability to collaborate in a complex, matrixed organization. Exceptional organizational and time management skills. Ability to manage multiple tasks and meet deadlines. Attention to detail and strong critical thinking skills. Excellent verbal and written communication skills. Proficiency in Microsoft Office Suite and capability to learn new software programs. Preferred Qualifications Experience in utilization and quality program management. Background in managed care. Peer review experience. Professional certifications such as CPHM, CPHQ, or CCMC. Molina Healthcare provides a competitive benefits and compensation package. We are an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $186,201.39 - $363,093 / ANNUAL. Actual compensation may vary based on geographic location, work experience, education, and skill level.

Created: 2026-03-04