Medical Director Medicaid

Location

Work from home (Pennsylvania)

Shift

Rotation (United States of America)

Scheduled Weekly Hours

40

Worker Type

Regular

Exemption Status

Yes

Job Summary

Lead clinical strategy, medical management, and regulatory performance for the Medicaid line of business across Pennsylvania. 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, ensuring contractual and regulatory compliance.

Key Responsibilities

Clinical Leadership & Medicaid Program Oversight

• 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. Ensure 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, maintaining a strong understanding of contractual and regulatory requirements in partnership with other GHP departments.

Regulatory, Accreditation & Quality

• 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.

Provider Engagement & Network Collaboration

• 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.

Cross‑Functional Partnership

• 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.

External Representation

• Act as the plan’s clinical spokesperson with the state Medicaid agency and advisory bodies; participate in accreditation committees, stakeholder forums, and community partnerships.
• Represent GHP in meetings with other MCOs and appropriately manage information shared between organizations.

Minimum Qualifications (Required)

• 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 (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 be willing to relocate.

Preferred Qualifications

• Direct Pennsylvania Medicaid experience (e.g., DHS engagement, PA DOH reporting).
• Background in population health, value‑based payment, behavioral health integration, and LTSS.
• Preferred Certification: 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.

Core Competencies

• 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.

Benefits

We offer healthcare benefits for full‑time and part‑time positions from day one, including vision, dental, and domestic partners. We encourage an atmosphere of collaboration, cooperation, and collegiality.

EEO Statement

We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.