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Medical Director


MOLINA HEALTHCARE – MEDICAL DIRECTOR - Columbus, Ohio

POSITION SUMMARY:
The Medical Director provides medical professional judgment for and oversight of the Utilization Management Program to ensure that the healthcare and services provided to Plan members are medically necessary, appropriate, meets contractual compliance and community medical practice standards.

Job Duties and Responsibilities:
The Medical Director is responsible for providing clinical oversight to the entire Medical Affairs Department and supporting other operational areas.

Day-to-day duties include:
• Reviews the medical necessity of authorization requests for inpatient and outpatient services.

This includes (a) evaluating the service requests in terms of clinical criteria and ODJFS regulations; (b) preparing and submitting denial language in the on-line authorization system; and communicating decisions with all appropriate personnel.
• Conducts working clinical rounds with nursing teams, providing both guidance on specific cases and education on managed care and disease processes in general.
• Participates in QI activities and committees, including support of clinical quality investigations.
• Analyses utilization trends and development of management strategies.
• Developments and implements clinical policies and procedures, as needed.
• Supports the provider services teams, as requested.
• Responsible for clinical oversight of the Utilization Management Program.

Provides leadership and participates in UM Dept.

meetings as an active member of the UM team, to discuss prior authorization, inpatient concurrent review, discharge planning and case management issues.

Promotes UM programs to meet all regulatory requirements.
• Evaluates referrals from the UM Dept.

staff which do not meet medical necessity and appropriateness criteria, and has final decision authority and accountability for approval or denial of payment for services.

Contacts referring or attending physicians to discuss cases which do not meet medical necessity or appropriateness criteria.

Functions as a liaison and educates the provider network regarding the UM Program, and assists in interpretation of policies, procedures, referral process, etc.
• Addresses appeals from providers and members for medical necessity and appropriateness.
• Assists the Chief Medical Officer with continuous Quality Improvement activities that help achieve NCQA accreditation.

Evaluates quality and utilization related issues, and is responsible for referrals for quality reviews and prepares information for the PRC for further evaluation and resolution.
• Responds to and serves as a resource to the UM Dept.

staff regarding collection and interpretation of member medical record information.
• Performs other duties as assigned.
• Ensures that authorization decisions are rendered by qualified medical personnel, without hindrance due to fiscal or administrative incent...

 


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