Clinical Director jobs at HCA Healthcare

JOB DESCRIPTION Job SummaryLeads and manages a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - 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 - Leads a team of medical directors responsible for assessing appropriateness and medical necessity of health care services provided to plan members. - Provides leadership and expertise in performance of prior authorization, inpatient concurrent review, discharge planning, care management and interdisciplinary care team (ICT) activities. - Recruits, hires, trains, mentors and develops medical director staff as needed. - Ensures that authorization decisions are rendered by qualified medical personnel and without hindrance due to fiscal or administrative incentives. - Analyzes data and identifies medical cost-savings and quality improvement opportunities. - Accounts for regulatory and accreditation performance of assigned team and responds to inquiries, issues and complaints from government and accreditation regulators. - Develops medical policies and procedures as needed. - Conducts peer review processes. Required Qualifications - At least 8 years of relevant experience, including clinical practice experience, and at least 2 years as a medical director in managed care setting supporting utilization management/quality management initiatives, or equivalent combination of relevant education and experience. - At least 3 years management/leadership experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. - Board Certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Demonstrated ability to make strategic decisions. - Knowledge of health care regulatory and legislative processes, including ability to read and interpret legislation. - Experience gaining consensus, and collaborating in a highly matrixed organization. - Experience demonstrating strong leadership, communication, consensus building, collaboration and financial acumen abilities. - Evidence-based clinical criteria competency. - Peer review, medical policy/procedure development, and provider contracting experience. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications - Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare 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: $214,132 - $417,557 / 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: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. + Marketplace UM reviews + MD licenses required for the following states: AZ, FL, TX, NV, WA, CT, KY, MS, NM, CA **Job Duties** + Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership position relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse incidents and quality of care concerns. Participates in preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality improvement staff. + Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements. + Reviews quality referred issues, focused reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process. + Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care. + Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care. + Ensures that medical protocols and rules of conduct for plan medical personnel are followed. + Develops and implements plan medical policies. + Provides implementation support for Quality Improvement activities. + Stabilizes, improves and educates the Primary Care Physician and Specialty networks. Monitors practitioner practice patterns and recommends corrective actions if needed. + Fosters Clinical Practice Guideline implementation and evidence-based medical practice. + Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management. + Actively participates in regulatory, professional and community activities. **JOB QUALIFICATIONS** **REQUIRED EDUCATION:** + Doctorate Degree in Medicine + Board Certified or eligible in a primary care specialty **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:** + 3+ years relevant experience, including: + 2 years previous experience as a Medical Director in a clinical practice. + Current clinical knowledge. + Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen. + Knowledge of applicable state, federal and third party regulations **REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:** Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. **PREFERRED EDUCATION:** Master's in Business Administration, Public Health, Healthcare Administration, etc. **PREFERRED EXPERIENCE:** + Peer Review, medical policy/procedure development, provider contracting experience. + Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines. + Experience in Utilization/Quality Program management + HMO/Managed care experience **PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:** Board Certification (Primary Care preferred). **PHYSICAL DEMANDS:** Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. \#PJHS \#LI-AC1 Pay Range: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryLeads and manages a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - 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 - Leads a team of medical directors responsible for assessing appropriateness and medical necessity of health care services provided to plan members. - Provides leadership and expertise in performance of prior authorization, inpatient concurrent review, discharge planning, care management and interdisciplinary care team (ICT) activities. - Recruits, hires, trains, mentors and develops medical director staff as needed. - Ensures that authorization decisions are rendered by qualified medical personnel and without hindrance due to fiscal or administrative incentives. - Analyzes data and identifies medical cost-savings and quality improvement opportunities. - Accounts for regulatory and accreditation performance of assigned team and responds to inquiries, issues and complaints from government and accreditation regulators. - Develops medical policies and procedures as needed. - Conducts peer review processes. Required Qualifications - At least 8 years of relevant experience, including clinical practice experience, and at least 2 years as a medical director in managed care setting supporting utilization management/quality management initiatives, or equivalent combination of relevant education and experience. - At least 3 years management/leadership experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. - Board Certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Demonstrated ability to make strategic decisions. - Knowledge of health care regulatory and legislative processes, including ability to read and interpret legislation. - Experience gaining consensus, and collaborating in a highly matrixed organization. - Experience demonstrating strong leadership, communication, consensus building, collaboration and financial acumen abilities. - Evidence-based clinical criteria competency. - Peer review, medical policy/procedure development, and provider contracting experience. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications - Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare 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: $214,132 - $417,557 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryLeads and manages a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - 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 - Leads a team of medical directors responsible for assessing appropriateness and medical necessity of health care services provided to plan members. - Provides leadership and expertise in performance of prior authorization, inpatient concurrent review, discharge planning, care management and interdisciplinary care team (ICT) activities. - Recruits, hires, trains, mentors and develops medical director staff as needed. - Ensures that authorization decisions are rendered by qualified medical personnel and without hindrance due to fiscal or administrative incentives. - Analyzes data and identifies medical cost-savings and quality improvement opportunities. - Accounts for regulatory and accreditation performance of assigned team and responds to inquiries, issues and complaints from government and accreditation regulators. - Develops medical policies and procedures as needed. - Conducts peer review processes. Required Qualifications - At least 8 years of relevant experience, including clinical practice experience, and at least 2 years as a medical director in managed care setting supporting utilization management/quality management initiatives, or equivalent combination of relevant education and experience. - At least 3 years management/leadership experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. - Board Certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Demonstrated ability to make strategic decisions. - Knowledge of health care regulatory and legislative processes, including ability to read and interpret legislation. - Experience gaining consensus, and collaborating in a highly matrixed organization. - Experience demonstrating strong leadership, communication, consensus building, collaboration and financial acumen abilities. - Evidence-based clinical criteria competency. - Peer review, medical policy/procedure development, and provider contracting experience. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications - Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare 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: $214,132 - $417,557 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryLeads and manages a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - 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 - Leads a team of medical directors responsible for assessing appropriateness and medical necessity of health care services provided to plan members. - Provides leadership and expertise in performance of prior authorization, inpatient concurrent review, discharge planning, care management and interdisciplinary care team (ICT) activities. - Recruits, hires, trains, mentors and develops medical director staff as needed. - Ensures that authorization decisions are rendered by qualified medical personnel and without hindrance due to fiscal or administrative incentives. - Analyzes data and identifies medical cost-savings and quality improvement opportunities. - Accounts for regulatory and accreditation performance of assigned team and responds to inquiries, issues and complaints from government and accreditation regulators. - Develops medical policies and procedures as needed. - Conducts peer review processes. Required Qualifications - At least 8 years of relevant experience, including clinical practice experience, and at least 2 years as a medical director in managed care setting supporting utilization management/quality management initiatives, or equivalent combination of relevant education and experience. - At least 3 years management/leadership experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. - Board Certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Demonstrated ability to make strategic decisions. - Knowledge of health care regulatory and legislative processes, including ability to read and interpret legislation. - Experience gaining consensus, and collaborating in a highly matrixed organization. - Experience demonstrating strong leadership, communication, consensus building, collaboration and financial acumen abilities. - Evidence-based clinical criteria competency. - Peer review, medical policy/procedure development, and provider contracting experience. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications - Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare 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: $214,132 - $417,557 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

JOB DESCRIPTION Job SummaryLeads and manages a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - 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 - Leads a team of medical directors responsible for assessing appropriateness and medical necessity of health care services provided to plan members. - Provides leadership and expertise in performance of prior authorization, inpatient concurrent review, discharge planning, care management and interdisciplinary care team (ICT) activities. - Recruits, hires, trains, mentors and develops medical director staff as needed. - Ensures that authorization decisions are rendered by qualified medical personnel and without hindrance due to fiscal or administrative incentives. - Analyzes data and identifies medical cost-savings and quality improvement opportunities. - Accounts for regulatory and accreditation performance of assigned team and responds to inquiries, issues and complaints from government and accreditation regulators. - Develops medical policies and procedures as needed. - Conducts peer review processes. Required Qualifications - At least 8 years of relevant experience, including clinical practice experience, and at least 2 years as a medical director in managed care setting supporting utilization management/quality management initiatives, or equivalent combination of relevant education and experience. - At least 3 years management/leadership experience. - Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and unrestricted in state of practice. - Board Certification. - Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff. - Demonstrated ability to make strategic decisions. - Knowledge of health care regulatory and legislative processes, including ability to read and interpret legislation. - Experience gaining consensus, and collaborating in a highly matrixed organization. - Experience demonstrating strong leadership, communication, consensus building, collaboration and financial acumen abilities. - Evidence-based clinical criteria competency. - Peer review, medical policy/procedure development, and provider contracting experience. - Strong verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications - Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare 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: $214,132 - $417,557 / 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: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. + Marketplace UM reviews + MD licenses required for the following states: AZ, FL, TX, NV, WA, CT, KY, MS, NM, CA **Job Duties** + Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership position relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse incidents and quality of care concerns. Participates in preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality improvement staff. + Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements. + Reviews quality referred issues, focused reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process. + Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care. + Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care. + Ensures that medical protocols and rules of conduct for plan medical personnel are followed. + Develops and implements plan medical policies. + Provides implementation support for Quality Improvement activities. + Stabilizes, improves and educates the Primary Care Physician and Specialty networks. Monitors practitioner practice patterns and recommends corrective actions if needed. + Fosters Clinical Practice Guideline implementation and evidence-based medical practice. + Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management. + Actively participates in regulatory, professional and community activities. **JOB QUALIFICATIONS** **REQUIRED EDUCATION:** + Doctorate Degree in Medicine + Board Certified or eligible in a primary care specialty **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:** + 3+ years relevant experience, including: + 2 years previous experience as a Medical Director in a clinical practice. + Current clinical knowledge. + Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen. + Knowledge of applicable state, federal and third party regulations **REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:** Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. **PREFERRED EDUCATION:** Master's in Business Administration, Public Health, Healthcare Administration, etc. **PREFERRED EXPERIENCE:** + Peer Review, medical policy/procedure development, provider contracting experience. + Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines. + Experience in Utilization/Quality Program management + HMO/Managed care experience **PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:** Board Certification (Primary Care preferred). **PHYSICAL DEMANDS:** Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. \#PJHS \#LI-AC1 Pay Range: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. + Marketplace UM reviews + MD licenses required for the following states: AZ, FL, TX, NV, WA, CT, KY, MS, NM, CA **Job Duties** + Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership position relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse incidents and quality of care concerns. Participates in preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality improvement staff. + Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements. + Reviews quality referred issues, focused reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process. + Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care. + Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care. + Ensures that medical protocols and rules of conduct for plan medical personnel are followed. + Develops and implements plan medical policies. + Provides implementation support for Quality Improvement activities. + Stabilizes, improves and educates the Primary Care Physician and Specialty networks. Monitors practitioner practice patterns and recommends corrective actions if needed. + Fosters Clinical Practice Guideline implementation and evidence-based medical practice. + Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management. + Actively participates in regulatory, professional and community activities. **JOB QUALIFICATIONS** **REQUIRED EDUCATION:** + Doctorate Degree in Medicine + Board Certified or eligible in a primary care specialty **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:** + 3+ years relevant experience, including: + 2 years previous experience as a Medical Director in a clinical practice. + Current clinical knowledge. + Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen. + Knowledge of applicable state, federal and third party regulations **REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:** Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. **PREFERRED EDUCATION:** Master's in Business Administration, Public Health, Healthcare Administration, etc. **PREFERRED EXPERIENCE:** + Peer Review, medical policy/procedure development, provider contracting experience. + Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines. + Experience in Utilization/Quality Program management + HMO/Managed care experience **PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:** Board Certification (Primary Care preferred). **PHYSICAL DEMANDS:** Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. \#PJHS \#LI-AC1 Pay Range: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. - 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. \#PJHS \#LI-AC1 \#HTF 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: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Molina's Behavioral Health function provides leadership and guidance for utilization management and case management programs for mental health and chemical dependency services and assists with implementing integrated Behavioral Health care management programs. **Knowledge/Skills/Abilities** Provides Psychiatric leadership for utilization management and case management programs for mental health and chemical dependency services. Works closely with the Regional Medical Directors to standardized utilization management policies and procedures to improve quality outcomes and decrease costs. - Provide regional medical necessity reviews and cross coverage - Standardizes UM practices and quality and financial goals across all LOBs - Responds to BH-related RFP sections and review BH portions of state contracts - Assist the BH MD lead trainers in the development of enterprise-wide teaching on psychiatric diagnoses and treatment - Provides second level BH clinical reviews, BH peer reviews and appeals - Supports BH committees for quality compliance. - Implements clinical practice guidelines and medical necessity review criteria - Tracks all clinical programs for BH quality compliance with NCQA and CMS - Assists with the recruitment and orientation of new Psychiatric MDs - Ensures all BH programs and policies are in line with industry standards and best practices - Assists with new program implementation and supports the health plan in-source BH services - Additional duties as assigned **Job Qualifications** **REQUIRED EDUCATION:** - Doctorate Degree in Medicine (MD or DO) with Board Certification in Psychiatry **REQUIRED EXPERIENCE:** - 2 years previous experience as a Medical Director in clinical practice - 3 years' experience in Utilization/Quality Program Management - 2+ years HMO/Managed Care experience - 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** Active and unrestricted State (TX) Medical License, free of sanctions from Medicaid or Medicare. **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. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. \#PJHS \#LI-AC1 Pay Range: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. - 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. \#PJHS \#LI-AC1 \#HTF 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: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. + Marketplace UM reviews + MD licenses required for the following states: AZ, FL, TX, NV, WA, CT, KY, MS, NM, CA **Job Duties** + Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership position relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse incidents and quality of care concerns. Participates in preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality improvement staff. + Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements. + Reviews quality referred issues, focused reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process. + Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care. + Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care. + Ensures that medical protocols and rules of conduct for plan medical personnel are followed. + Develops and implements plan medical policies. + Provides implementation support for Quality Improvement activities. + Stabilizes, improves and educates the Primary Care Physician and Specialty networks. Monitors practitioner practice patterns and recommends corrective actions if needed. + Fosters Clinical Practice Guideline implementation and evidence-based medical practice. + Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management. + Actively participates in regulatory, professional and community activities. **JOB QUALIFICATIONS** **REQUIRED EDUCATION:** + Doctorate Degree in Medicine + Board Certified or eligible in a primary care specialty **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:** + 3+ years relevant experience, including: + 2 years previous experience as a Medical Director in a clinical practice. + Current clinical knowledge. + Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen. + Knowledge of applicable state, federal and third party regulations **REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:** Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. **PREFERRED EDUCATION:** Master's in Business Administration, Public Health, Healthcare Administration, etc. **PREFERRED EXPERIENCE:** + Peer Review, medical policy/procedure development, provider contracting experience. + Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines. + Experience in Utilization/Quality Program management + HMO/Managed care experience **PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:** Board Certification (Primary Care preferred). **PHYSICAL DEMANDS:** Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. \#PJHS \#LI-AC1 Pay Range: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. - 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: $161,914.25 - $315,733 / 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. - 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: $161,914.25 - $315,733 / 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: $161,914.25 - $315,733 / 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. - 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: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. + Marketplace UM reviews + MD licenses required for the following states: AZ, FL, TX, NV, WA, CT, KY, MS, NM, CA **Job Duties** + Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure a high quality of patient care, ensuring that patients receive the most appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership position relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse incidents and quality of care concerns. Participates in preparation for NCQA and URAC certifications. Develops and provides leadership for NCQA-compliant clinical quality improvement activity (QIA) in collaboration with the clinical lead, the medical director, and quality improvement staff. + Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements. + Reviews quality referred issues, focused reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer. + Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process. + Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care. + Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care. + Ensures that medical protocols and rules of conduct for plan medical personnel are followed. + Develops and implements plan medical policies. + Provides implementation support for Quality Improvement activities. + Stabilizes, improves and educates the Primary Care Physician and Specialty networks. Monitors practitioner practice patterns and recommends corrective actions if needed. + Fosters Clinical Practice Guideline implementation and evidence-based medical practice. + Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management. + Actively participates in regulatory, professional and community activities. **JOB QUALIFICATIONS** **REQUIRED EDUCATION:** + Doctorate Degree in Medicine + Board Certified or eligible in a primary care specialty **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:** + 3+ years relevant experience, including: + 2 years previous experience as a Medical Director in a clinical practice. + Current clinical knowledge. + Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen. + Knowledge of applicable state, federal and third party regulations **REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:** Current state Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare. **PREFERRED EDUCATION:** Master's in Business Administration, Public Health, Healthcare Administration, etc. **PREFERRED EXPERIENCE:** + Peer Review, medical policy/procedure development, provider contracting experience. + Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines. + Experience in Utilization/Quality Program management + HMO/Managed care experience **PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:** Board Certification (Primary Care preferred). **PHYSICAL DEMANDS:** Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. \#PJHS \#LI-AC1 Pay Range: $161,914.25 - $315,733 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.