Medical Director Medical Operations- Geisinger Health Plan

Location

Work from home (Pennsylvania)

Shift

Days (United States of America)

Scheduled Weekly Hours

40

Worker Type

Regular

Exemption Status

Yes

Job Summary

The Medical Director is dedicated to the implementation of the Health Plan's primary goals and objectives. The Medical Director will act as a visible champion of continuous improvement in the quality of care and services. The Medical Director for the Health Plan is a medical team leader for all Health Plans' activity within a regional network for one of the Plan's operating geographical areas. The position is based within each the Health Plan/Geisinger operating regions.

Job Duties

Takes a leadership role in medical management of all Health Plan inpatient activity to include acute inpatient, LTAC, observation, SNF, Rehab and various alternatives related to inpatient care such as ambulatory surgery.

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 and 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 and claims check.
• Supports the Evidence of Insurability and Over Age Dependent process.
• Provides support to the Geisinger 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 and 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 and Therapeutics Committee.

Work is typically performed in a clinical and office environment. Travel may be required. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

Position Details

• Education:
• Doctor of Medicine or Doctor of Osteopathic Medicine- (Required)

Experience

• Certification(s) and License(s):
• Licensed Medical Doctor - State of Pennsylvania

Skills

Office Administration

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, we encourage an atmosphere of collaboration, cooperation and collegiality.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.