Chief Medical Officer jobs at HCA Healthcare - 43 jobs

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. Essential Job Duties - Determines appropriateness and medical necessity of health care services provided to plan members. - 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. -Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. - Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. - Assumes leadership 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 investigation of adverse incidents and quality of care concerns. - Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. - 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. - 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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. - Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. - Fosters clinical practice guideline implementation and evidence-based medical practices. - Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. - Actively participates in regulatory, professional and community activities. Required Qualifications - At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. - Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. - Board certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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 Pay Range: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. Essential Job Duties - Determines appropriateness and medical necessity of health care services provided to plan members. - 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. -Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. - Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. - Assumes leadership 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 investigation of adverse incidents and quality of care concerns. - Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. - 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. - 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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. - Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. - Fosters clinical practice guideline implementation and evidence-based medical practices. - Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. - Actively participates in regulatory, professional and community activities. Required Qualifications - At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. - Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. - Board certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryProvides medical oversight and expertise related to behavioral health and chemical dependency services, and assists with implementation of integrated behavioral health care programs within specific markets/regions. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Provides behavioral health oversight and clinical leadership for health plan and/or market specific utilization management and care management behavioral health programs and chemical dependency services - working closely with regional medical directors to standardize behavioral health utilization management policies and procedures to improve quality outcomes and decrease costs. - Facilitates behavioral health-related regional medical necessity reviews and cross coverage. - Standardizes behavioral health-related utilization management, quality, and financial goals across all lines of businesses. - Responds to behavioral health-related requests for proposal (RFP) sections and reviews behavioral health portions of state contracts. - Assists behavioral health medical director lead trainers in the development of enterprise-wide education on psychiatric diagnoses and treatment. - Provides second level behavioral health clinical reviews, peer reviews and appeals. - Supports behavioral health committees for quality compliance. - Implements behavioral health specific clinical practice guidelines and medical necessity review criteria. - Tracks all clinical programs for behavioral health quality compliance with National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS). - Assists with the recruitment and orientation of new psychiatric medical directors. - Ensures all behavioral health programs and policies are in line with industry standards and best practices. - Assists with new program implementation and supports for health plan in-source behavioral health services. Required Qualifications - At least 3 of relevant experience, including 2 years of medical practice experience in psychiatry/behavioral health, or equivalent combination of relevant education and experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state (NY) of practice. - Board Certification in Psychiatry. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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 Pay Range: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

**Per Diem Hospice Medical Directorin Beautiful Northern, CO** **Remote Only & Flexible Schedule** **BANNER HEALTH and the Home Care & Hospice Division** , one of the countrys premier, nonprofit health care networks with more than 1,500 physicians and advance practice providers, **has an excellent opportunity for a compassionate, skilled clinician to join our interdisciplinary team! This position serves the growing community in Northern Colorado in partnership with the current care team.** Utilizing a multidisciplinary approach, the qualified candidate will provide remote support to the Home Care & Hospice team of Advanced Practice Providers. **Position Requirements and Information:** + BC/BE in a relevant specialty + Colorado state licensed + Fellowship training in Hospice & Palliative Medicine - NOT REQUIRED + Experience preferred, new graduates also welcome to apply + Flexible schedule primarily providing back-up coverage for the acting Medical Director **Compensation & Benefits:** + **$140/hr** + Malpractice and Tail Coverage **About the area:** With more than 300 days of sunshine, Northern Colorado is one of the best places to live and work offering spectacular views along the Rocky Mountain Front Range, great weather, endless recreational activities, cultural amenities, education, and professional opportunities. + Within one hour of majestic Rocky Mountain National Park & 90 minutes to world-class ski resorts + Numerous outdoor activities including golf, biking, hiking, camping, rock climbing, hunting, and fishing + Thriving cultural and retail sectors + Highly educated workforce & broad-based business sector leading to substantial growth along the front range + Variety of public and private education options for K-12 and easy access to three major universities **PLEASE SUBMIT YOUR CV TODAY FOR IMMEDIATE CONSIDERATION** As an equal opportunity employer, Banner Health values culture and encourages applications from individuals with varied experiences and backgrounds. Banner Health is an EEO Employer. POS15101 Banner Health complies with applicable federal and state laws and does not discriminate based on race, color, national origin, religion, sex, sexual orientation, gender identity or expression, age, or disability.

JOB DESCRIPTION Job SummaryProvides medical oversight and expertise related to behavioral health and chemical dependency services, and assists with implementation of integrated behavioral health care programs within specific markets/regions. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties * Provides behavioral health oversight and clinical leadership for health plan and/or market specific utilization management and care management behavioral health programs and chemical dependency services - working closely with regional medical directors to standardize behavioral health utilization management policies and procedures to improve quality outcomes and decrease costs. * Facilitates behavioral health-related regional medical necessity reviews and cross coverage. * Standardizes behavioral health-related utilization management, quality, and financial goals across all lines of businesses. * Responds to behavioral health-related requests for proposal (RFP) sections and reviews behavioral health portions of state contracts. * Assists behavioral health medical director lead trainers in the development of enterprise-wide education on psychiatric diagnoses and treatment. * Provides second level behavioral health clinical reviews, peer reviews and appeals. * Supports behavioral health committees for quality compliance. * Implements behavioral health specific clinical practice guidelines and medical necessity review criteria. * Tracks all clinical programs for behavioral health quality compliance with National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS). * Assists with the recruitment and orientation of new psychiatric medical directors. * Ensures all behavioral health programs and policies are in line with industry standards and best practices. * Assists with new program implementation and supports for health plan in-source behavioral health services. Required Qualifications * At least 3 of relevant experience, including 2 years of medical practice experience in psychiatry/behavioral health, or equivalent combination of relevant education and experience. * Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. * Board Certification in Psychiatry. * Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. * Ability to work cross-collaboratively within a highly matrixed organization. * Strong organizational and time-management skills. * Ability to multi-task and meet deadlines. * Attention to detail- available to work PST zone. * Critical-thinking and active listening skills. * Decision-making and problem-solving skills. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications * Experience with utilization/quality program management. * Managed care experience. * Peer review experience. * 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 Pay Range: $186,201.39 - $363,093 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

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. Essential Job Duties - Determines appropriateness and medical necessity of health care services provided to plan members. - 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. -Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. - Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. - Assumes leadership 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 investigation of adverse incidents and quality of care concerns. - Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. - 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. - 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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. - Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. - Fosters clinical practice guideline implementation and evidence-based medical practices. - Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. - Actively participates in regulatory, professional and community activities. Required Qualifications - At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. - Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. - Board certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryProvides medical oversight and expertise related to behavioral health and chemical dependency services, and assists with implementation of integrated behavioral health care programs within specific markets/regions. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Provides behavioral health oversight and clinical leadership for health plan and/or market specific utilization management and care management behavioral health programs and chemical dependency services - working closely with regional medical directors to standardize behavioral health utilization management policies and procedures to improve quality outcomes and decrease costs. - Facilitates behavioral health-related regional medical necessity reviews and cross coverage. - Standardizes behavioral health-related utilization management, quality, and financial goals across all lines of businesses. - Responds to behavioral health-related requests for proposal (RFP) sections and reviews behavioral health portions of state contracts. - Assists behavioral health medical director lead trainers in the development of enterprise-wide education on psychiatric diagnoses and treatment. - Provides second level behavioral health clinical reviews, peer reviews and appeals. - Supports behavioral health committees for quality compliance. - Implements behavioral health specific clinical practice guidelines and medical necessity review criteria. - Tracks all clinical programs for behavioral health quality compliance with National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS). - Assists with the recruitment and orientation of new psychiatric medical directors. - Ensures all behavioral health programs and policies are in line with industry standards and best practices. - Assists with new program implementation and supports for health plan in-source behavioral health services. Required Qualifications - At least 3 of relevant experience, including 2 years of medical practice experience in psychiatry/behavioral health, or equivalent combination of relevant education and experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state (NY) of practice. - Board Certification in Psychiatry. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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 Pay Range: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. Essential Job Duties * Determines appropriateness and medical necessity of health care services provided to plan members. * 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. •Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. * Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. * Assumes leadership 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 investigation of adverse incidents and quality of care concerns. * Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. * 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. * 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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. * Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. * Fosters clinical practice guideline implementation and evidence-based medical practices. * Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. * Actively participates in regulatory, professional and community activities. Required Qualifications * At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. * Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. * Board certification. * Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. * Ability to work cross-collaboratively within a highly matrixed organization. * Strong organizational and time-management skills. * Ability to multi-task and meet deadlines. * Attention to detail. * Critical-thinking and active listening skills. * Decision-making and problem-solving skills. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications * Experience with utilization/quality program management. * Managed care experience. * Peer review experience. * 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 Pay Range: $186,201.39 - $363,093 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

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. Essential Job Duties * Determines appropriateness and medical necessity of health care services provided to plan members. * 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. •Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. * Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. * Assumes leadership 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 investigation of adverse incidents and quality of care concerns. * Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. * 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. * 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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. * Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. * Fosters clinical practice guideline implementation and evidence-based medical practices. * Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. * Actively participates in regulatory, professional and community activities. Required Qualifications * At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. * Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. * Board certification. * Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. * Ability to work cross-collaboratively within a highly matrixed organization. * Strong organizational and time-management skills. * Ability to multi-task and meet deadlines. * Attention to detail. * Critical-thinking and active listening skills. * Decision-making and problem-solving skills. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications * Experience with utilization/quality program management. * Managed care experience. * Peer review experience. * 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 Pay Range: $186,201.39 - $363,093 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

JOB DESCRIPTION Job SummaryProvides medical oversight and expertise related to behavioral health and chemical dependency services, and assists with implementation of integrated behavioral health care programs within specific markets/regions. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Provides behavioral health oversight and clinical leadership for health plan and/or market specific utilization management and care management behavioral health programs and chemical dependency services - working closely with regional medical directors to standardize behavioral health utilization management policies and procedures to improve quality outcomes and decrease costs. - Facilitates behavioral health-related regional medical necessity reviews and cross coverage. - Standardizes behavioral health-related utilization management, quality, and financial goals across all lines of businesses. - Responds to behavioral health-related requests for proposal (RFP) sections and reviews behavioral health portions of state contracts. - Assists behavioral health medical director lead trainers in the development of enterprise-wide education on psychiatric diagnoses and treatment. - Provides second level behavioral health clinical reviews, peer reviews and appeals. - Supports behavioral health committees for quality compliance. - Implements behavioral health specific clinical practice guidelines and medical necessity review criteria. - Tracks all clinical programs for behavioral health quality compliance with National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS). - Assists with the recruitment and orientation of new psychiatric medical directors. - Ensures all behavioral health programs and policies are in line with industry standards and best practices. - Assists with new program implementation and supports for health plan in-source behavioral health services. Required Qualifications - At least 3 of relevant experience, including 2 years of medical practice experience in psychiatry/behavioral health, or equivalent combination of relevant education and experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. - Board Certification in Psychiatry. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail- available to work PST zone. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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 Pay Range: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. Essential Job Duties - Determines appropriateness and medical necessity of health care services provided to plan members. - 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. -Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. - Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. - Assumes leadership 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 investigation of adverse incidents and quality of care concerns. - Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. - 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. - 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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. - Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. - Fosters clinical practice guideline implementation and evidence-based medical practices. - Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. - Actively participates in regulatory, professional and community activities. Required Qualifications - At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. - Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. - Board certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryProvides medical oversight and expertise related to behavioral health and chemical dependency services, and assists with implementation of integrated behavioral health care programs within specific markets/regions. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Provides behavioral health oversight and clinical leadership for health plan and/or market specific utilization management and care management behavioral health programs and chemical dependency services - working closely with regional medical directors to standardize behavioral health utilization management policies and procedures to improve quality outcomes and decrease costs. - Facilitates behavioral health-related regional medical necessity reviews and cross coverage. - Standardizes behavioral health-related utilization management, quality, and financial goals across all lines of businesses. - Responds to behavioral health-related requests for proposal (RFP) sections and reviews behavioral health portions of state contracts. - Assists behavioral health medical director lead trainers in the development of enterprise-wide education on psychiatric diagnoses and treatment. - Provides second level behavioral health clinical reviews, peer reviews and appeals. - Supports behavioral health committees for quality compliance. - Implements behavioral health specific clinical practice guidelines and medical necessity review criteria. - Tracks all clinical programs for behavioral health quality compliance with National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS). - Assists with the recruitment and orientation of new psychiatric medical directors. - Ensures all behavioral health programs and policies are in line with industry standards and best practices. - Assists with new program implementation and supports for health plan in-source behavioral health services. Required Qualifications - At least 3 of relevant experience, including 2 years of medical practice experience in psychiatry/behavioral health, or equivalent combination of relevant education and experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state (NY) of practice. - Board Certification in Psychiatry. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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 Pay Range: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. Essential Job Duties - Determines appropriateness and medical necessity of health care services provided to plan members. - 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. -Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. - Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. - Assumes leadership 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 investigation of adverse incidents and quality of care concerns. - Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. - 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. - 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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. - Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. - Fosters clinical practice guideline implementation and evidence-based medical practices. - Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. - Actively participates in regulatory, professional and community activities. Required Qualifications - At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. - Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. - Board certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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 Pay Range: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. Essential Job Duties - Determines appropriateness and medical necessity of health care services provided to plan members. - 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. -Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. - Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. - Assumes leadership 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 investigation of adverse incidents and quality of care concerns. - Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. - 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. - 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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. - Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. - Fosters clinical practice guideline implementation and evidence-based medical practices. - Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. - Actively participates in regulatory, professional and community activities. Required Qualifications - At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. - Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. - Board certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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 Pay Range: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryProvides medical oversight and expertise related to behavioral health and chemical dependency services, and assists with implementation of integrated behavioral health care programs within specific markets/regions. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Provides behavioral health oversight and clinical leadership for health plan and/or market specific utilization management and care management behavioral health programs and chemical dependency services - working closely with regional medical directors to standardize behavioral health utilization management policies and procedures to improve quality outcomes and decrease costs. - Facilitates behavioral health-related regional medical necessity reviews and cross coverage. - Standardizes behavioral health-related utilization management, quality, and financial goals across all lines of businesses. - Responds to behavioral health-related requests for proposal (RFP) sections and reviews behavioral health portions of state contracts. - Assists behavioral health medical director lead trainers in the development of enterprise-wide education on psychiatric diagnoses and treatment. - Provides second level behavioral health clinical reviews, peer reviews and appeals. - Supports behavioral health committees for quality compliance. - Implements behavioral health specific clinical practice guidelines and medical necessity review criteria. - Tracks all clinical programs for behavioral health quality compliance with National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS). - Assists with the recruitment and orientation of new psychiatric medical directors. - Ensures all behavioral health programs and policies are in line with industry standards and best practices. - Assists with new program implementation and supports for health plan in-source behavioral health services. Required Qualifications - At least 3 of relevant experience, including 2 years of medical practice experience in psychiatry/behavioral health, or equivalent combination of relevant education and experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. - Board Certification in Psychiatry. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail- available to work PST zone. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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 Pay Range: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. Essential Job Duties * Determines appropriateness and medical necessity of health care services provided to plan members. * 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. •Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. * Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. * Assumes leadership 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 investigation of adverse incidents and quality of care concerns. * Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. * 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. * 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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. * Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. * Fosters clinical practice guideline implementation and evidence-based medical practices. * Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. * Actively participates in regulatory, professional and community activities. Required Qualifications * At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. * Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. * Board certification. * Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. * Ability to work cross-collaboratively within a highly matrixed organization. * Strong organizational and time-management skills. * Ability to multi-task and meet deadlines. * Attention to detail. * Critical-thinking and active listening skills. * Decision-making and problem-solving skills. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications * Experience with utilization/quality program management. * Managed care experience. * Peer review experience. * 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 Pay Range: $186,201.39 - $363,093 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

JOB DESCRIPTION Job SummaryProvides medical oversight and expertise related to behavioral health and chemical dependency services, and assists with implementation of integrated behavioral health care programs within specific markets/regions. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties - Provides behavioral health oversight and clinical leadership for health plan and/or market specific utilization management and care management behavioral health programs and chemical dependency services - working closely with regional medical directors to standardize behavioral health utilization management policies and procedures to improve quality outcomes and decrease costs. - Facilitates behavioral health-related regional medical necessity reviews and cross coverage. - Standardizes behavioral health-related utilization management, quality, and financial goals across all lines of businesses. - Responds to behavioral health-related requests for proposal (RFP) sections and reviews behavioral health portions of state contracts. - Assists behavioral health medical director lead trainers in the development of enterprise-wide education on psychiatric diagnoses and treatment. - Provides second level behavioral health clinical reviews, peer reviews and appeals. - Supports behavioral health committees for quality compliance. - Implements behavioral health specific clinical practice guidelines and medical necessity review criteria. - Tracks all clinical programs for behavioral health quality compliance with National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS). - Assists with the recruitment and orientation of new psychiatric medical directors. - Ensures all behavioral health programs and policies are in line with industry standards and best practices. - Assists with new program implementation and supports for health plan in-source behavioral health services. Required Qualifications - At least 3 of relevant experience, including 2 years of medical practice experience in psychiatry/behavioral health, or equivalent combination of relevant education and experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. - Board Certification in Psychiatry. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail- available to work PST zone. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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 Pay Range: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. Essential Job Duties - Determines appropriateness and medical necessity of health care services provided to plan members. - 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. -Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. - Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. - Assumes leadership 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 investigation of adverse incidents and quality of care concerns. - Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. - 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. - 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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. - Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. - Fosters clinical practice guideline implementation and evidence-based medical practices. - Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. - Actively participates in regulatory, professional and community activities. Required Qualifications - At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. - Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. - Board certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Ability to work cross-collaboratively within a highly matrixed organization. - Strong organizational and time-management skills. - Ability to multi-task and meet deadlines. - Attention to detail. - Critical-thinking and active listening skills. - Decision-making and problem-solving skills. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications - Experience with utilization/quality program management. - Managed care experience. - Peer review experience. - 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: $186,201.39 - $363,093 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. Essential Job Duties * Determines appropriateness and medical necessity of health care services provided to plan members. * 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. •Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and under-utilization. * Educates and interacts with network, group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. * Assumes leadership 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 investigation of adverse incidents and quality of care concerns. * Participates in preparation for national committee for quality assurance (NCQA) and utilization review accreditation commission (URAC) certifications. * 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. * 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, Pharmacy and Therapeutics (P&T) and other committees 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 and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care. * Ensures 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 primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed. * Fosters clinical practice guideline implementation and evidence-based medical practices. * Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management. * Actively participates in regulatory, professional and community activities. Required Qualifications * At least 3 years health care experience, including at least 2 years of medical practice experience, or equivalent combination of relevant education and experience. * Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state of practice. * Board certification. * Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. * Ability to work cross-collaboratively within a highly matrixed organization. * Strong organizational and time-management skills. * Ability to multi-task and meet deadlines. * Attention to detail. * Critical-thinking and active listening skills. * Decision-making and problem-solving skills. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications * Experience with utilization/quality program management. * Managed care experience. * Peer review experience. * 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: $186,201.39 - $363,093 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.