Medical Director Medical Operations- Geisinger Health Plan

Geisinger•Work from home (Pennsylvania), PA

8d•Remote

About The Position

The Medical Director is dedicated to the implementation of the Health Plan's primary goals and objectives. The Medical Director will act as a visible champion of continuous improvement in the quality of care and services. The Medical Director for the Health Plan is a medical team leader for all Health Plans' activity within a regional network for one of the Plan's operating geographical areas. The position is based within each the Health Plan/Geisinger operating regions.

Requirements

Doctor of Medicine or Doctor of Osteopathic Medicine- (Required)
Licensed Medical Doctor - State of Pennsylvania
Office Administration

Responsibilities

Takes a leadership role in medical management of all Health Plan inpatient activity to include acute inpatient, LTAC, observation, SNF, Rehab and various alternatives related to inpatient care such as ambulatory surgery.
Responsible for the continued development and implementation of the Health Plan Medical Management Plan for inpatient services.
Work closely with all Health Plan Medical Directors to further manage medical goals in each region.
Work closely with the Medical Directors for Medical Home and Informatics in implementing and monitoring the Health Plan Medical Management plan especially as inpatient care relates to large case management and disease management.
Supports as appropriate the medical component of retrospective claims audit and claims check.
Supports the Evidence of Insurability and Over Age Dependent process.
Provides support to the Geisinger Home Health nurses working on DME, Home Health and Rehabilitation issues.
Provides guidance and interpretation on issues of medical appropriateness, benefit application, and level of care necessary to include out of network care.
Assure proper and complete documentation of all necessary paperwork within the required timelines.
Participates in Medical Director On-Call and On-Duty and Appeals Committee activities.
Responsible administratively for the practitioner and provider appeals process along with the Director of Medical Management and Medical Management managers.
Responsible for quality, accuracy, and timely completion of all medical directors correspondence related to denials and appeals.
Participates on the Plan Pharmacy and Therapeutics Committee.