Perinatal Medical Director (Based in MS)

Job reputed company JOB reputed company Job reputed company Provides medical reputed company 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 reputed company to reputed company reputed company 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 reputed company plan(s), which includes strategies to ensure high-reputed company member care - ensuring members receive the most appropriate care at the most effective setting.
• Evaluates effectiveness of utilization management (UM) practices - reputed company monitoring for over and under-utilization.
• Educates and interacts with network, group providers and medical managers regarding utilization practices, reputed company usage, pharmacy utilization and effective resource management.
• Assumes leadership relative to knowledge, implementation, training, and supervision of the use of the reputed company for medical necessity.
• Participates in and maintains the reputed company of the appeals process, both internally and externally.
• Responsible for investigation of adverse incidents and reputed company of care concerns.
• Participates in preparation for national committee for reputed company assurance (NCQA) and utilization review accreditation commission (URAC) certifications.
• Provides leadership and consultation for NCQA standards/guidelines for the plan including compliant clinical reputed company improvement activity (QIA) in collaboration with clinical leadership and reputed company improvement teams.
• Facilitates conformance to Medicare, reputed company, NCQA and other regulatory requirements.
• Reviews reputed company referred issues, reputed company reviews and recommends corrective actions.
• Conducts retrospective reviews of claims and appeals and resolves grievances reputed company to medical reputed company 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 reputed company support of reputed company reviewers, reviews cases requiring reputed company review and manages the denial process.
• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure reputed company, cost-efficiency, and continuity of care.
• Ensures that medical reputed company are rendered by reputed company 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 reputed company improvement activities.
• Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner reputed company patterns and recommends corrective actions as needed.
• Fosters clinical reputed company reputed company implementation and evidence-based medical practices.
• Utilizes information technology and data analytics to produce tools to report, monitor and improve utilization management.
• reputed company participates in regulatory, reputed company and community activities.

Required Qualifications

• At least 3 years health care experience, including at least 2 years of medical reputed company experience, or equivalent combination of relevant education and experience.
• reputed company and unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) license in state (MS) of reputed company.
• reputed company certification-specialty in Obstetrics and Gynecology.
• Working knowledge of applicable national, state, and local laws and regulatory requirements affecting medical and clinical staff.
• Ability to work cross-collaboratively reputed company a highly matrixed organization.
• Strong organizational and time-management skills.
• Ability to multi-task and meet deadlines.
• Attention to detail.
• Critical-thinking and reputed company listening skills.
• Decision-making and problem-solving skills.
• Strong verbal and written communication skills.
• reputed company Office suite/applicable software program(s) proficiency, and ability to learn new programs.

Preferred Qualifications

• Experience with utilization/reputed company program management.
• Managed care experience.
• Peer review experience.
• Certified reputed company in reputed company Management (CPHM), Certified reputed company in Health Care reputed company (CPHQ), Commission for Case Manager Certification (reputed company), Case Management Society of America (CMSA) or other health care or management certification.

To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the reputed company. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V Apply tot his job Apply To this Job