Medical Director - Physical Medicine New Mexico
Company: Molina Healthcare
Location: Albuquerque
Posted on: April 16, 2024
Job Description:
Must live in New Mexico
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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.
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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.
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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:.
- 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 (NM) Medical license without restrictions to practice
and free of sanctions from Medicaid or Medicare.
PREFERRED EDUCATION:
Medical Doctor or Doctor of Osteopathy
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.
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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. Pay Range: $161,914.25 - $315,732.79 / ANNUAL
*Actual compensation may vary from posting based on geographic
location, work experience, education and/or skill level.
Keywords: Molina Healthcare, Albuquerque , Medical Director - Physical Medicine New Mexico, Executive , Albuquerque, New Mexico
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