Provides executive level strategy and leadership to the health plan in the development and execution of care management and utilization management programs. Develops clinical practice guidelines and oversees appropriateness and medical necessity of services provided to plan members - targeting improvements in efficiency and satisfaction for members and providers. Partners with executive leadership team to provide cohesive direction towards company goals. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care.
• Provides executive strategy, vision and direction to the health plan for the medical affairs function. Provides strategic support for design/implementation/execution for programs related to quality improvement, utilization management, care management, predictive modeling and disease management. Responsible for performance and financial results of medical affairs function, and keeps executive leadership apprised.
• Leads the health plan's analysis of medical care cost and utilization data. Leads and manages the development of techniques to effectively correct identified and anticipated utilization problems while assuring that members receive the care they need.
• Provides leadership, direction and oversight functions to the health plan’s medical management staff to achieve best in class performance as defined by identified metrics.
• Demonstrates a positive leadership role in key health plan medical management initiatives aimed at optimizing utilization of medical resources.
• Oversees and directs the rendering of medical management decisions at all levels of the health plan that maximize benefits for members while pursuing and supporting corporate objectives.
• At least 12 years of relevant health care leadership experience, including clinical practice experience, and at least 2 years as a medical director in managed care organization supporting utilization management/quality program management, or equivalent combination of relevant education and experience.
• At least 7 years health care management/leadership experience.
• Active and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO). License must be active and restricted in state of practice.
• Board certification.
• Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff.
• Experience demonstrating strong leadership and communication skills, consensus building, collaborative ability and financial acumen.
• Demonstrated ability to make strategic decisions.
• Excellent verbal and written communication skills.
• Microsoft Office proficiency.
• Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) certification, or other health care or management certification.
• Prior experience with process improvement activities, policy and procedure development, and operational efficiency.
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