Medical Director- National (Lee's Summit)

Medical Director

GEHA (Government Employees Health Association, Inc., pronounced G.E.H.A.) is a nonprofit member association that provides medical and dental benefits to more than two million federal employees and retirees, military retirees and their families. We celebrate diversity and are committed to creating an inclusive environment for all employees.

GEHA has one mission : To empower federal workers to be healthy and well.

Offering one of the largest medical and dental benefit provider networks available to federal employees in the United States, GEHA empowers health and wellness by meeting its members where they are, when they need care. We serve our members with products they value and a personalized customer experience, sustained by a nimble and efficient organization.

The Medical Director will support innovation in care delivery, cost containment, and quality improvement. This role focuses on clinical review of escalated claims and appeals, third-party vendor relationships and performance review, and collaboration on enterprise-wide clinical strategy. The Medical Director demonstrates professionalism and leadership skills across clinical and non-clinical teams.

Skills

Duties and Responsibilities :

• Reviews medical and pharmacy cases to ensure compliance with evidence-based medicine guidelines and G.E.H.A clinical programs. Documents rationale for decisions and communicates collaboratively with appropriate staff. Ensures reviews are completed timely and according to policy, as determined by type of review.
• Ensures clinical decisions are in compliance with plan documents. Assists clinical staff in the appropriate interpretation of plan documents, as it relates to clinical services.
• Provides direction and support for escalated clinical cases. Is available to clinical and pharmacy staff for urgent decisions. Assists program directors in preparing appropriate documentation for OPM.
• Determines the need for external review of medical and / or pharmacy cases. Evaluates the external review organizations for quality of reviews and makes recommendations regarding continued use of the organization.
• Develops internal guidelines to support internal reviews. Educates clinical and pharmacy staff in consistent application of guidelines.
• Protects GEHA from excessive and unnecessary claims by gathering medical data and making medical judgments on unique and / or questionable cases. Interacts with the legal team as needed and clearly documents GEHA's position.
• Partners with Quality, Medical Management, Strategic Business Insights (SBI), and Care Management teams to support successful execution of clinical programs.
• Serves as an internal medical expert for clinical and nonclinical teams. Collaborates with clinical staff to determine cost-effective membership specific approaches to meet the needs of members within the confines of the plan documents. Meets regularly with case management staff to review high dollar cases.
• Provides medical assistance in updating claims payment policy. Researches preventive guidelines and interprets for appropriate coding in the system.
• Provides daily medical support to external partners and GEHA staff participating in clinical program development and execution.
• Assists the Special Investigations Unit in review of cases with utilization management issues. Makes medical necessity decisions and participates in the appeal process as appropriate.
• Assists with clinical editor configuration and on-going review of new edits to prevent inappropriate payment or over-payment.

Knowledge, Skills, and Abilities :

Preferred Qualifications :

Work-at-home requirements :

How we value you :

While this is a remote opportunity, at this time GEHA does not hire employees from U.S. territories or the following states : Alaska, Hawaii, California, Washington, Oregon, Colorado, Wyoming, Montana, New York, Connecticut, Vermont, Pennsylvania, Maine.

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. The annual base salary range for this position is $227,254 - $320,346 USD.

GEHA is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. 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. We are committed to creating an inclusive environment for all employees. Our diversity drives innovation deepens connections and strengthens our organization.

GEHA is headquartered in Lee's Summit, Missouri, in the Kansas City area. We recognize the importance of balance and flexibility and offer hybrid and work-from-home options for many of our roles.