Medical Director-GHP

Profile

Job Summary

The Medical Director, Health Services along with the Vice President, Medical Operations, is directly responsible for all Plan activities related to the member. He/she will be dedicated to the goals and objectives of GHP and will act as a visible champion of continuous improvement in quality of care and service and the appropriate management of medical resources.

Job Duties

Duties and Responsibilities:

Medical Management:

• Takes a leadership role in medical management of all Health Plan inpatient and outpatient activity including but not limited to acute inpatient, LTAC, observation, SNF, Rehab and various alternatives related to inpatient care such as ambulatory surgery.
• The position will be 80% in GHP/20% in clinical practice.
• 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 & 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/claims check.
• Supports the Evidence of Insurability and Over Age Dependent process.
• Provides support to the GHS 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 & 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 & Therapeutics Committee.
• Responsible for support of pharmacy prior auth/denial/appeal process.

Provider Network:

• Actively educates employed & contracted health practitioners in regards to managed care principles and Geisinger Health Plan policies and procedures
• May participate in the following medical management activities in the network as determined by CMO
• Visits network facilities and practitioners
• Supports Regional Network Management Representatives and Recruiters in development and expansion of the regional network, as well as the overall satisfaction of the network
• Provides guidance and interpretation on issues of medical appropriateness, benefit application as appropriate, level of care necessary to include out-of-network care
• Assures analysis, distribution, and discussion of all CRMS Best Practice reports and other Physician Profile Reports.
• Encourages use of guidelines both preventive and clinical.
• Coordinates with and supports Disease Management Programs as well as Medical Home Programs
• Works with specialists to achieve Medical Management goals.
• Supports Care Coordination Team and Case Managers in the region.
• Analyzes Pharmacy Prescribing Reports. Provides feedback in coordination with Network Management and Pharmacy to contracted physicians.
• Assures documentation of activities with summary to Geisinger Health Plan Vice President, Chief Medical Officer

Quality Improvement:

• Reports any quality concerns to the QI Department for investigation.
• Participates in the Medical Care Review Committee.
• Participates on the Quality Improvement Committee (“QIC”).

Administration:

• Functions as a member of the Health Plans operations team and administrative staff.
• Responsible for implementation of Geisinger Health Plan policy and procedures in a supervisory capacity.
• Participates on Geisinger Health Plan Quality Improvement Committee and/or any one of its subcommittees.
• Participates in weekly Medical Directors meeting.
• Participates on Medical Management Committee.

Qualifications:

Requires current Pennsylvania license to practice without restrictions. Requires an MD/DO degree with preference toward a primary care specialty with at least 3 – 5 years of clinical practice experience. Previous experience as a medical director in a Managed Care Organization is desirable. Requires board certification in chosen specialty. Requires a dedication to the philosophy of managed care and continuous quality improvement of clinical care and service. The ability to communicate effectively at all levels of large complex organization is essential.

Organizational Relationships:

The Medical Director, Medical Management reports to the Health Plan Senior Management Team with specific supervisory relationship to the Vice President, Chief Medical Officer of Geisinger Health Plan.

Position Details

Education

Doctor of Medicine or Doctor of Osteopathic Medicine- (Required)

Experience

Certification(s) and License(s)

Licensed Medical Doctor - State of Pennsylvania

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.

We are an Affirmative Action, Equal Opportunity Employer. Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.

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