- Molina Healthcare (Sterling Heights, MI)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... Medicare , Medicaid, NCQA and other regulatory requirements. + Reviews...experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- Molina Healthcare (Sterling Heights, MI)
- …3+ years HMO/Managed Care experience **OR** 5 years experience as a Molina Medical Director + Demonstrated experience in Utilization/Quality Program management + ... Summary** Responsible for serving as the primary liaison between administration and medical staff. Assures the ongoing development and implementation of policies and… more
- Molina Healthcare (Sterling Heights, MI)
- JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and medical necessity of services provided to members, targeting ... and cost-effective member care. Essential Job Duties * Determines appropriateness and medical necessity of health care services provided to plan members. * Supports… more
- Molina Healthcare (Sterling Heights, MI)
- **JOB DESCRIPTION** **Job Summary** Responsible for analysis of Medicaid and Medicare financial reports, trend, and opportunities. Includes evaluation of and ... recommendations relating to business opportunities, Medicare bids, investments, financial regulations, and similar financial projects...early signs of trends or other issues related to medical care cost. + Design and perform actuarial studies… more
- Molina Healthcare (Sterling Heights, MI)
- …quality improvement activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. + Facilitates conformance to ... Medicare , Medicaid, NCQA and other regulatory requirements. + Reviews...experience, including: + 2 years previous experience as a Medical Director in a clinical practice. +… more
- Molina Healthcare (Sterling Heights, MI)
- …Certification in Psychiatry **REQUIRED EXPERIENCE:** * 2 years previous experience as a Medical Director in clinical practice * 3 years' experience in ... (TX) Medical License, free of sanctions from Medicaid or Medicare . **Preferred Experience** * Peer Review, medical policy/procedure development, provider… more
- Henry Ford Health System (Troy, MI)
- …to meet urgent Part D and pharmacy analysis needs. This new Director role establishes dedicated, in-house pharmacy actuarial expertise to strengthen financial ... competitive advantage in 2026 and beyond. Position Summary The Director , Actuarial Services - Pharmacy / Part D is...Health Alliance Plan (HAP), with a primary focus on Medicare Part D and broader enterprise pharmacy strategy. This… more
- Molina Healthcare (Sterling Heights, MI)
- …reviews behavioral health portions of state contracts. * Assists behavioral health medical director lead trainers in the development of enterprise-wide education ... JOB DESCRIPTION Job SummaryProvides medical oversight and expertise related to behavioral health...National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS). * Assists with the… more
- Molina Healthcare (Sterling Heights, MI)
- …and Joint Operating Committees. * Manages and reports network adequacy for Medicare , Marketplace, and Medicaid services. * In conjunction with direct management and ... recontracting initiatives. Implements cost control initiatives to positively influence the Medical Care Ratio (MCR) in each contracted region. * Leads preparation… more
- McLaren Health Care (Lake Orion, MI)
- …current RAI manual guidelines and oversee accurate and timely completion of all Medicare residents' MDS assessments. The MDS Coordinator will act as resource for the ... Medicare MDS Case Manager RN's, LTC nurses and all...MDS coordinator will work in collaboration with the rehab director and nurse manager in an effort to provide… more
- Elara Caring (Rochester Hills, MI)
- …package + Comprehensive onboarding and mentorship + Opportunities for advancement + Medical , dental, and vision benefits, 401K match and paid time off for ... experience In a Health Care setting + Knowledge of Medicare and Medicaid, home health care benefits, policies and...perform job responsibilities You will report to the Branch Director , Alternative Branch Director , or Regional Branch… more
- Henry Ford Health System (Troy, MI)
- …programs compliance requirements. Responsible, under the direction of the Director - Compliance, to provide overall strategic direction to manage compliance ... programs compliance oversight and regulations may be specific to Medicare , Medicaid, Office of Personnel Management (OPM) the Affordable...Ford is one of the nation's most respected academic medical centers and is leading the Future of Health:… more
- Integra Partners (Troy, MI)
- The UM Coordinator assists and supports the clinical team (UM Nurses/ Medical Director ) with administrative and non-clinical tasks related to processing ... been submitted with authorization requests + Contact requesting providers to obtain medical records or other necessary documentation related to specific UM request +… more
- Molina Healthcare (Sterling Heights, MI)
- …with national quality and risk adjustment VPs, Regional Directors of Quality/Risk, Director of Value Based Programs, and local health plan resources. + Responsible ... program & contract design and implementation for marketplace, Medicaid and/or Medicare + Experience in a complex healthcare delivery environment, specifically with… more
- Molina Healthcare (Sterling Heights, MI)
- …Tighter knit proximity ongoing after contract. * In conjunction with Director /Manager, Provider Contracts, negotiates Complex Provider contracts including but not ... and/or language. Assists with cost control strategies that positively impact the Medical Care Ratio (MCR) within each region. * Advises Network Provider Contract… more
- Henry Ford Health System (Troy, MI)
- …processes within value-based reimbursement models and initiatives. Reporting to the Director , Risk Adjustment and Value-Based Payment, the Program Manager is ... both departmental staff and multi-disciplinary teams. + Knowledge of Medicare , Medicaid, Blue Cross and other third-party payers billing...Ford is one of the nation's most respected academic medical centers and is leading the Future of Health:… more