Medical Director - National

GEHA is a leader in health services for federal employees and related customers, serving our chosen markets with low-cost offerings and best-in-class customer care, sustained by a nimble and efficient organization.

An Executive Order was released stating that federal contractors must require COVID-19 vaccinations for all US employees. As a company that works on federal contracts, we have a legal requirement to comply with the executive order, if it is enforced.

Please note that the salary information is a general guideline only. GEHA considers factors such as (but not limited to) scope and responsibilities of the position, candidate's work experience, education/training, key skills, internal peer equity, as well as, market and business considerations when extending an offer.

Duties and Responsibilities

• Provides and supports medical expertise of recommendations and direction throughout organization and serves as POC of major initiatives across multiple divisions across a function

• Provides medical leadership of all for utilization management, cost containment, claims accuracy, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, claims logic and medical review of complex, controversial, or experimental medical services.

• Participate in a Queue for utilization management reviews including prior authorization, inpatient concurrent review, post-acute care authorizations and concurrent reviews, and appeals. This includes application of benefit, coverage policy for medical necessity and claims adjudication.

• Works collaboratively as a division consultant to Population Health/Pharmacy and Quality operations team to support business initiatives in Clinical Operations.

• Promotes evidence-based medicine and ensures all policies/programs are based on sound clinical standards. Collaborates with external medical staff to improve program offerings and/or processes and positively impact health outcomes.

• Facilitates UM consistently and compliantly using benefit plan information, applicable federal and state regulations, clinical guidelines, emerging codes, configuration accuracy, new trends and best practice principles

• Works with cross functional team to understand claims trends, spend, and development and implementation of strategy for mitigation/containment.

• Accountable to drive member satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions

• Accountable of the Brochure/Clinical Policy/Clinical Guideline development and implementation as appropriate. Works in concert with operational directors and other Medical Directors to insure consistent administration of policies.

• Responsible for Accreditation knowledge pertaining to standards including implementation, supervision, oversight, and evaluation of the UM program.

• The Medical Director develops, refines, reviews and acts upon utilization review reporting metrics both national and occasionally at the market level.

Requirements: Knowledge, Skills, and Abilities

• Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)

• Must possess an active unrestricted medical license to practice medicine or a health profession

• Currently licensed in the state of Missouri or willing to being Licensed in Missouri

• Minimum of 10 years of clinical experience or any combination of education and experience, which would provide an equivalent background

• Minimum of five (5) years of leadership experience in health care administration

• Ability to adhere to Central Standard Time zone for attendance

• Works to achieve quality outcomes according to evidence-based practice for members with a focus on service and improving clinical outcomes and improve claims trends.
  
• Effective Communicator/Collaborator

• Requires effective verbal and written skills.

Reporting Relationships and Contacts

• Reports to Senior level leader

Working Conditions

Office environment. Remote or Hybrid, Work from Home.

#LI-Hybrid

GEHA is an Equal Opportunity Employer. GEHA will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. Our company's corporate headquarters is located in Lee's Summit near Douglas Rd and I-470 with a total of five locations in the Kansas City metropolitan area.