Medical Director ( CA)

JOB DESCRIPTION Job Summary Provides 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. Experience conducting Medi-cal reviews Essential Job Duties u2022 Determines appropriateness and medical necessity of health care services provided to plan members. u2022 Supports 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. u2022Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. u2022 Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. u2022 Assumes leadership relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity. u2022 Participates in and maintains the integrity of the appeals process, both internally and externally. u2022 Responsible for investigation of adverse incidents and quality of care concerns. u2022 Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. u2022 Provides 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. u2022 Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements. u2022 Reviews quality referred issues, focused reviews and recommends corrective actions. u2022 Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. u2022 Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and other committees as directed by the chief medical officer. u2022 Evaluates authorization requests in timely support of nurse reviewers, reviews cases requiring concurrent review and manages the denial process. u2022 Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care. u2022 Ensures 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. u2022 Ensures medical protocols and rules of conduct for plan medical personnel are followed. u2022 Develops and implements plan medical policies. u2022 Provides implementation support for quality improvement activities. u2022 Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. u2022 Fosters clinical practice guideline implementation and evidence-based medical practices. u2022 Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. u2022 Actively participates in regulatory, professional and community activities. Required Qualifications u2022 At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. u2022 Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. u2022 Board certification. u2022 Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. u2022 Ability to work cross-collaboratively within a highly matrixed organization. u2022 Strong organizational and time-management skills. u2022 Ability to multi-task and meet deadlines. u2022 Attention to detail. u2022 Critical-thinking and active listening skills. u2022 Decision-making and problem-solving skills. u2022 Strong verbal and written communication skills. u2022 Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications u2022 Experience with utilization/quality program management. u2022 Managed care experience. u2022 Peer review experience. u2022 Certified 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. To 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 #PJHS #LI-AC1 Pay Range: $161,914.25 - $315,733 / ANNUAL Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2025-10-04