Medical Director Medicaid

• 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.
• Serves 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

• 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.

• 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 .
• 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.

• 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.

At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh FoodFarmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencingprograms, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 1 ... 3 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers. What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.

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