• Responsible for interpreting managed care regulations and developing, communicating and executing the implementation policies and procedures to ensure the company meets the federal and state guidelines.
• Directs the team responsible for creation and maintenance of Molina's Prior Authorization lists and gives clinical guidance to tool maintenance
• Responsible for reviewing all current Policy & Procedures and provide recommended changes based on evolving clinical and industry standards.
• Monitors and analyzes various organization trends, activities, and coverage policies, as well as recognizes, assesses and communicates important policy issues to stakeholders.
• Follows up on the impact of trends and initiatives that impact the organization. Renders policy developments into evocative strategic advice and guidance.
• Researches questions and issues from internal physicians and nurses related to developed medical policies or other clinical issues arising from daily operations.
• Develops and delivers educational training regarding policies to Medical Directors and clinical review teams.
• Works closely with compliance and regulatory team and collaborates with subject matter experts and clinical leaders.
• Coordinates communication of medical policy decisions to necessary internal stakeholders and maintains accurate libraries of policies and related clinical summary documents.
• Participates in all pertinent company training and development opportunities to grow and develop business knowledge, skills and leadership competencies.
• Responsible for driving the Molina Healthcare mission, culture through values and customer service standards to the community and healthcare providers, including physicians within the guidelines established by company policies and government regulations.
• Other duties as assigned
• Doctorate Degree in Medicine (MD or DO)
• 7+ years' experience as a Medical Director in managed care
• 10+ years' experience in Utilization Management
• 5+ years' leadership experience, preferably in a managed care environment
• Experience demonstrating strong management and communication skills, consensus building and collaborative ability.
• Graduate degree in public health or business administration preferred
• Knowledge of NCQA, HEDIS, Medicaid, Marketplace and Medicare managed care preferred
• Experience treating or managing care for a culturally diverse population preferred.
Preferred License, Certification, Association
• Board Certification in Internal Medicine or Family Medicine preferred
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.