Location:
Work from home (Pennsylvania)
Shift:
Rotation (United States of America)
Scheduled Weekly Hours:
40
Worker Type:
Regular
Exemption Status:
Yes
Job Summary:
Location: Pennsylvania (onsite/hybrid/remote with periodic in state travel)
Reports to: Chief Medical Officer
Department: Health Services / Medical Management
FLSA: Exempt | Employment Type: Full time
Job Duties:
Role Summary
Lead clinical strategy, medical management, and regulatory performance for our Medicaid line of business across Pennsylvania (and any adjacent markets we enter). Partner with Quality, Utilization Management, Case/Disease Management, Pharmacy, Behavioral Health, Provider Network, and Compliance to deliver highquality, costeffective care and strong outcomes for Medicaid members. Serve as the primary physician liaison with the state Medicaid agency and key provider partners, and ensure contractual and regulatory compliance.
Key Responsibilities
Clinical leadership & Medicaid program oversight
- 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 peertopeer discussions. Ensure determinations are clinically sound and timely.
- Oversee grievance and appeals clinical reviews and author evidencebased 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.
Regulatory, accreditation & quality
- 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., HEDISaligned 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.
Provider engagement & network collaboration
- 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 valuebased models, performance feedback, appeals resolution themes, and market growth priorities.
Crossfunctional partnership
- 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.
External representation
- Act as the plans 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 MCOs and appropriately manages information shared between organizations
Minimum Qualifications (Required)
- MD or DO, board certified (ABMS/AOA).
- Active Pennsylvania medical licenseor eligibility to obtain PA licensure within 6 months of hire.
- 5 67+ years clinical practice plus 3+ years in a healthplan medical leadership role (Medical Director or Deputy) specific to Medicaid (multistate plan experience requirede28094e.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.
Preferred Qualifications
- Direct Pennsylvania Medicaid experience (e.g., DHS engagement, PA DOH reporting, CHC/HealthChoices familiarity).
- Background in population health, valuebased 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.
Core Competencies
- Evidencebased decisionmaking; 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.
Position Details:
Location: Pennsylvania (onsite/hybrid/remote with periodic instate travel)
Education:
Doctor of Medicine or Doctor of Osteopathic Medicine- (Required)
Experience:
Minimum of 5 years-Clinical (Required), Minimum of 3 years-Health Insurance/Managed Care (Required)
Certification(s) and License(s):
Certified Professional in Healthcare Quality - The National Association for Healthcare Quality (NAHQ), Licensed Medical Doctor - State of Pennsylvania
Skills:
Medicaid, Office Administration, Population Health Management, Value Based Healthcare
