Medical Director Molina Healthcare · Bothell, WA

Job Summary

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. 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…