Talent.com
Medical Director (Medicare)

Medical Director (Medicare)

Molina HealthcareVancouver, Washington, United States
job_description.job_card.variable_hours_ago
serp_jobs.job_preview.job_type
  • serp_jobs.job_card.full_time
job_description.job_card.job_description

JOB DESCRIPTION

Job Summary

Responsible for serving as the primary liaison between administration and medical staff.

Assures the ongoing development and implementation of policies and procedures that guide and support the provisions of medical staff services.

Maintains a working knowledge of applicable national, state, and local laws and regulatory requirements affecting the medical and clinical staff.

Job Duties

Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards.

Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.

Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most effective setting.

Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization.

Assumes a leadership position relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity.

Participates in and maintains the integrity of the appeals process, both internally and externally.

Responsible for the investigation of adverse incidents and quality of care concerns.

Participates in preparation for NCQA and URAC certifications.

Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality improvement staff.

Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.

Reviews quality referred issues, focused reviews and recommends corrective actions.

Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.

Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer.

Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process.

Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care.

Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.

Ensures that medical protocols and rules of conduct for plan medical personnel are followed.

Develops and implements plan medical policies.

Provides implementation support for Quality Improvement activities.

Stabilizes, improves and educates the Primary Care Physician and Specialty networks.

Monitors practitioner practice patterns and recommends corrective actions if needed.

Fosters Clinical Practice Guideline implementation and evidence-based medical practice.

Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management.

Actively participates in regulatory, professional and community activities.

JOB QUALIFICATIONS

REQUIRED EDUCATION :

Doctorate Degree in Medicine

Board Certified or eligible in a primary care specialty

REQUIRED EXPERIENCE / KNOWLEDGE, SKILLS & ABILITIES :

3+ years relevant experience, including :

2 years previous experience as a Medical Director in a clinical practice.

Current clinical knowledge.

Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.

Knowledge of applicable state, federal and third party regulations

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION :

Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare.

PREFERRED EDUCATION :

Master’s in Business Administration, Public Health, Healthcare Administration, etc.

PREFERRED EXPERIENCE :

Peer Review, medical policy / procedure development, provider contracting experience.

Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group / IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.

Experience in Utilization / Quality Program management

HMO / Managed care experience

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION :

Board Certification (Primary Care preferred).

PHYSICAL DEMANDS :

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and / or hazardous working conditions. Must have the ability to sit for long periods.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

To all current Molina employees : If you are interested in applying for this position, please apply through the intranet job listing.

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.
serp_jobs.job_alerts.create_a_job

Medical Director • Vancouver, Washington, United States

Job_description.internal_linking.related_jobs
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
Medical Director, US Licensed

Medical Director, US Licensed

VirtualVocationsVancouver, Washington, United States
serp_jobs.job_card.full_time
A company is looking for a Medical Director - US Medical Lead - Evenity (Bone).Key Responsibilities Support the development and execution of US product medical strategy and lifecycle management ...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
Physician (MD / DO) - Anesthesiology - General / Other in Hillsboro, OR

Physician (MD / DO) - Anesthesiology - General / Other in Hillsboro, OR

LocumJobsOnlineHillsboro, OR, US
serp_jobs.job_card.full_time
LocumJobsOnline is working with CompHealth to find a qualified Anesthesiology MD in Hillsboro, Oregon, 97123!.Hillsboro is the 5th-largest city in the state of Oregon and is the county seat of Wash...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
Senior Manager Clinical Biomarkers

Senior Manager Clinical Biomarkers

VirtualVocationsPortland, Oregon, United States
serp_jobs.job_card.full_time
A company is looking for a Senior Manager of Clinical Biomarkers.Key Responsibilities Lead the development and execution of clinical biomarker plans aligned with clinical development strategy Ov...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
Senior Manager, Medical Writing

Senior Manager, Medical Writing

VirtualVocationsAloha, Oregon, United States
serp_jobs.job_card.full_time
A company is looking for a Senior Manager, Medical Writing (Remote).Key Responsibilities Lead complex writing assignments and ensure timely completion of scientifically accurate projects Manage ...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
Hospice Medical Director

Hospice Medical Director

PRIMROSE HOSPICE CARE INC.Portland, OR, US
serp_jobs.job_card.full_time
Join Us in Bringing Hospice Back to Its .Primrose Hospice Care is formed by career healthcare providers who are dedicated to returning to the heart of hospice care——putting pa...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
Associate Practice Manager

Associate Practice Manager

VirtualVocationsPortland, Oregon, United States
serp_jobs.job_card.full_time
A company is looking for an Associate Practice Manager.Key Responsibilities Assist in overseeing administrative, care coordination, and field support teams to ensure timely and high-quality patie...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
Hospice Medical Director (Portland)

Hospice Medical Director (Portland)

PRIMROSE HOSPICE CARE INC.Portland, Oregon Metropolitan Area, US
serp_jobs.job_card.part_time
Join Us in Bringing Hospice Back to Its.Primrose Hospice Care is formed by career healthcare providers who are dedicated to returning to theheart of hospice careputting patients, families, and care...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
Medical Director & Chief, Division of Geriatric Medicine

Medical Director & Chief, Division of Geriatric Medicine

MaineHealthPortland, US
serp_jobs.job_card.full_time
Relocation assistance offered to eligible candidates!.Medical Director & Chief, Division of Geriatric Medicine.Suzi Osher Endowed Chair of Geriatrics, Maine Medical Center.The Medical Director ...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
Assistant Nurse Manager - Short Stay

Assistant Nurse Manager - Short Stay

Providence Health and ServicesClackamas, OR, US
serp_jobs.job_card.full_time
Description Assistant RN Manager - Short Stay at Providence Portland Medical Center.This is a full time, exempt position.We are offering fle...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
Director of Nursing (Up to $10K Sign On Bonus) Full Time

Director of Nursing (Up to $10K Sign On Bonus) Full Time

Miramont PointeClackamas, OR, US
serp_jobs.job_card.full_time
Miramont Pointe Senior Living is looking for an experienced and passionate.Assisted Living, Memory Care, and Respite Care. We are proud recipients of the.AHCA / NCAL Bronze National Quality Award.Silv...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
Nurse Practitioner (NP) - Pediatrics - General / Other in Canby, OR

Nurse Practitioner (NP) - Pediatrics - General / Other in Canby, OR

LocumJobsOnlineCanby, OR, US
serp_jobs.job_card.full_time +1
LocumJobsOnline is working with CompHealth to find a qualified Pediatrics NP in Canby, Oregon, 97013!.A small, family-focused clinic in Southern Portland is seeking a part-time Pediatric Nurse Prac...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
Delaware Licensed Medical Director

Delaware Licensed Medical Director

VirtualVocationsVancouver, Washington, United States
serp_jobs.job_card.full_time
A company is looking for a Medical Director for long term care.Key Responsibilities Ensure outstanding medical care and optimal health outcomes for residents Provide direct patient care while ov...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
Medical Director - Arizona Licensed

Medical Director - Arizona Licensed

VirtualVocationsVancouver, Washington, United States
serp_jobs.job_card.full_time
A company is looking for a Clinical Advocacy and Support Medical Director, Internist, Surgery or Plastic Surgery Preferred - Remote. Key Responsibilities Conduct coverage reviews based on individu...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
  • serp_jobs.job_card.promoted
Medical Director - Utilization Management

Medical Director - Utilization Management

VirtualVocationsPortland, Oregon, United States
serp_jobs.job_card.full_time
A company is looking for a Medical Director Utilization Management - Clinical Advocacy and Support.Key Responsibilities : Conduct coverage reviews and render coverage determinations based on membe...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
State Licensed Behavioral Health Director

State Licensed Behavioral Health Director

VirtualVocationsVancouver, Washington, United States
serp_jobs.job_card.full_time
A company is looking for a Senior Director, Utilization Management - Behavioral Health.Key Responsibilities Lead and oversee behavioral health management within the utilization management organiz...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
Manager Nursing - Psych-Adolescent

Manager Nursing - Psych-Adolescent

Providence Health and ServicesOregon City, OR, US
serp_jobs.job_card.full_time
Description $10,000 Hiring Bonus for eligible external hires that meet required qualifications and conditions for payment.Providence offers ...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
Nurse Practitioner (NP) - Pediatrics - General / Other in Oregon City, OR

Nurse Practitioner (NP) - Pediatrics - General / Other in Oregon City, OR

LocumJobsOnlineOregon City, OR, US
serp_jobs.job_card.full_time
LocumJobsOnline is working with CompHealth to find a qualified Pediatrics NP in Oregon City, Oregon, 97045!.A small, family-focused clinic in Southern Portland is seeking a Pediatric Nurse Practiti...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
Physician (MD / DO) - Pediatrics - General / Other in Oregon City, OR

Physician (MD / DO) - Pediatrics - General / Other in Oregon City, OR

LocumJobsOnlineOregon City, OR, US
serp_jobs.job_card.full_time
LocumJobsOnline is working with CompHealth to find a qualified Pediatrics MD in Oregon City, Oregon, 97045!.Oregon City, OR, is a historic and scenic community that offers physicians the opportunit...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
New Mexico Licensed Behavioral Medical Director

New Mexico Licensed Behavioral Medical Director

VirtualVocationsVancouver, Washington, United States
serp_jobs.job_card.full_time
A company is looking for a Behavioral Medical Director, licensed and residency in New Mexico, to work remotely.Key Responsibilities Ensure delivery of cost-effective quality care incorporating ev...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
Healthcare Industry Success Leader

Healthcare Industry Success Leader

VirtualVocationsVancouver, Washington, United States
serp_jobs.job_card.full_time
A company is looking for an Industry Success Leader (HCLS).Key Responsibilities Serve as a Consulting Leader, leveraging domain expertise to improve client business outcomes Own and develop a bo...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours