Medical Director Medicaid

Geisinger•Work from home (Pennsylvania), PA

1d•Hybrid

About The Position

This role serves as the primary physician liaison with the state Medicaid agency and key provider partners, ensuring contractual and regulatory compliance. The Medical Director will lead clinical strategy, medical management, and regulatory performance for the Medicaid line of business in Pennsylvania and any adjacent markets. This position requires a strong understanding of contractual and regulatory requirements and involves partnering with various departments to deliver high-quality, cost-effective care and strong outcomes for Medicaid members.

Requirements

MD or DO, board certified (ABMS/AOA).
Active Pennsylvania medical license or eligibility to obtain PA licensure within 6 months of hire.
5–7+ years clinical practice plus 3+ years in a health‑plan medical leadership role (Medical Director or Deputy) specific to Medicaid (multi‑state plan experience required—e.g., oversight in at least one additional state or a regional program).
Demonstrated experience with utilization management, appeals/grievances, and medical policy in a managed care setting.
Working knowledge of NCQA/URAC standards and state Medicaid regulatory requirements; familiarity with CMS expectations for managed care.
Must primarily reside in PA and have a home address in PA or willing to relocate.
Doctor of Medicine or Doctor of Osteopathic Medicine- (Required)
Minimum of 3 years-Health Insurance/Managed Care (Required)
Minimum of 5 years-Clinical (Required)
Licensed Medical Doctor - State of Pennsylvania
Medicaid
Office Administration
Population Health Management
Value Based Healthcare

Nice To Haves

Direct Pennsylvania Medicaid experience (e.g., DHS engagement, PA DOH reporting, CHC/HealthChoices familiarity).
Background in population health, value‑based payment, behavioral health integration, and LTSS.
Certified Professional in Healthcare Quality (CPHQ). Or obtain upon hire within the first year of employment.
Familiarity with InterQual/MCG criteria and care management platforms; comfort using data to guide clinical operations and provider performance.
Evidence‑based decision‑making; concise clinical writing for determinations and appeals.
Collaborative leadership across UM, Quality, Pharmacy, BH, Network, and Compliance.
Executive presence with regulators, providers, and internal leadership.

Responsibilities

Lead clinical strategy, medical management, and regulatory performance for our Medicaid line of business across Pennsylvania (and any adjacent markets we enter).
Partner with Quality, Utilization Management, Case/Disease Management, Pharmacy, Behavioral Health, Provider Network, and Compliance to deliver high‑quality, cost‑effective care and strong outcomes for Medicaid members.
Serve as the primary physician liaison with the state Medicaid agency and key provider partners, and ensure contractual and regulatory compliance.
Provide clinical direction for the Medicaid product, including medical policy, clinical guidelines, and care model design across UM/CM/DM.
Provide physician leadership for utilization management (prospective, concurrent, retrospective), complex case reviews, and peer‑to‑peer discussions, ensuring determinations are clinically sound and timely.
Oversee grievance and appeals clinical reviews and author evidence‑based rationales.
Serve as clinical lead for GHP on meetings with DHS and other external stakeholders with strong understanding of contractual and regulatory requirements, in partnership other GHP departments.
Ensure compliance with state Medicaid contract requirements and with NCQA/URAC, CMS, and state Department of Health rules; support surveys, audits, and reporting.
Drive quality improvement (e.g., HEDIS‑aligned initiatives), close gaps in care, and monitor outcomes and utilization trends; partner with Quality to design performance interventions.
Maintain familiarity with Pennsylvania regulatory expectations (e.g., DOH reporting under applicable code) and represent the plan in required state meetings.
Serve as clinical liaison to hospitals, systems, and practices; educate on medical policies/criteria (e.g., InterQual/MCG), practice guidelines, and performance opportunities.
Collaborate with Provider Network on value‑based models, performance feedback, appeals resolution themes, and market growth priorities.
Partner with Pharmacy on formulary strategy and prior authorization criteria; with Behavioral Health on integrated medical/behavioral management; with Social Care/Population Health on SDoH and equity initiatives.
Contribute physician expertise to clinical analytics, trend reviews, fraud/waste/abuse investigations, and policy updates.
Act as the plan’s clinical spokesperson with the state Medicaid agency and advisory bodies; participate in accreditation committees, stakeholder forums, and community partnerships.
Represents GHP in meetings with other MCO’s and appropriately manages information shared between organizations.