Chief Medical Officer, MedicareLong Beach, California Job ID 1902366
Molina Segment Operations jobs are responsible for the development and administration of Segment specific operational departments, programs and services, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulatory requirements.
The CMO – Medicare Segment will report to the Senior Vice President for the Medicare Segment and be focused on Molina's Medicare population (MAPD, D-SNP, MMP). This role provides national strategic direction and oversight, and provides updates directly to senior leadership, advisory and oversight committees.
• Leads the Medicare Segment'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 our members receive the care they need.
• Offers a positive leadership role in key Medicare Segment medical management initiatives aimed a optimizing utilization of medical resources
• Experience in establishing or leading the following types of Duals & Medicare (MAPD, D-SNP & MMP) national programs/initiatives using clinical and industry best practices:
o Post-acute care (“SNFist” Skilled Nursing Facility programs)
o Model of Care
o Palliative Care
o Diabetes Prevention
o Home Health
o Prior Authorizations/Referrals
• Knowledgeable in Medicare STARs Program to impact/drive improved clinical performance
• Provides national best practice strategic direction and oversight for Medicare population management (including case management, utilization management, auditing and training)
• Creates necessary cross-functional forums and uses data analysis to identify opportunities for medical cost trend and quality improvement to positively influence member care outcomes
• Leads development and implementation of national Medicare medical policy, including recommendations for modifications to improve efficiency and effectiveness. Designs standardized protocols, develops policy and ensures timely implementation in collaboration with Health Plan Presidents and Medicare Segment leader, as well as the enterprise Clinical Policy Committee.
• Responsible for ensuring compliance with medical policy and maintaining compliance with all federal, state and local regulatory guidelines
• Designs standardized protocols, develops policy and ensures timely implementation with corporate and health plan input.
• Ensures adequate training occurs from knowledgeable staff and coordinates with other departments as needed.
• Focuses on continual refinement of operational processes by using process improvement principles (PDSA, Lean Six Sigma, etc.).
• Develops, performs and promotes interdepartmental integration and collaboration to enhance clinical services.
• Manages and evaluates team members in the performance of various clinical management activities.
• Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators.
• Collaborates with other functional areas that interface with the Medicare Segment including medical management, network contracting & provider relations, member services, claims management, payment integrity, pharmacy, quality and risk adjustment.
• Acts as a critical Medicare Segment Clinical Leader for external providers, regulatory (local, state and federal) and accrediting agencies.
• Identifies potential areas of non-compliance by overseeing audits and provides advice and guidance to operational areas regarding effective processes, and policies and procedures.
• Collaborates with internal and external business partners to provide guidance and recommendations around the development, maintenance and enhancement of programs, products and services. Accountable for Medicare Segment readiness for internal and external audits (local, state and federal) and the administration of industry best practices.
• Ensures appropriate preparation and the successful outcome of the utilization management program compliance audits.
• Ensures Department policies, procedures and activities maintain adherence to, and are compliant with all state, federal, and delegating entity regulations and policies.
• Performs other duties and participates in organization projects as assigned.
• State Registered Nurse and/or active Medical Degree, unrestricted and in good standing.
• Knowledge of Medicare Managed Care products (MAPD, D-SNP and MMP plans)
• Knowledge of CMS regulatory requirements
• 5+ years of technical experience, preferably in a Medical Director role
• 5+ years of established clinical experience
• Demonstrated ability to make strategic decisions
• Experience in leading teams focused on quality management and utilization management
• Prior experience with process improvement activities, policy & procedure development, and operational efficiency.
• Knowledge of health care regulatory and legislative process; ability to read and interpret legislation.
• Strong analytical and research skills required.
• Strong verbal and written communication skills required.
• Demonstrated ability to manage multiple complex priorities, often with limited timeframes.
• Interpersonal skills; ability to interact effectively and professionally with all levels in the organization.
• Detail orientation and organizational skills; ability to meet deadlines on time.
• Experience with Microsoft Office products including SharePoint, Word, Excel and Access.
• MD or DO degree specialized in Geriatric Medicine
• Board Certified in an approved American Board of Medical Specialties (ABMS) Medical Specialty
• Master's Degree in Business Administration, Public Health, Healthcare Administration, Social Work or related field.
• 10+ years managed care experience with emphasis on Duals & Medicare populations (MAPD, D-SNP & MMP)
• Peer Review, medical policy/procedure development, provider contracting experience
Preferred License, Certification, Association
• Utilization Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), Commission for Case Manager Certification (CCMC), Case Management Society of America (CMSA) or other healthcare or management certification.
• Lean Six Sigma
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.