Molina Healthcare

Key Responsibilities

• • 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.