Medical Director-National

Position Title:            Medical Director-National
Open Positions:        1
Posted Date:              August 5, 2025
Location:                    Remote
Department:               Clinical Administration
Supervisor:                Roxane Sanders
 
 
Apply online at: https://geha.wd5.myworkdayjobs.com/GEHACareers/job/Remote/Medical-Director--National_R-005106
 
Summary
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.
 
Duties

• 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.

• Doctor of Medicine degree from an accredited institution.
• Current, unrestricted medical license and evidence of completion of required CME credits
• Board certification in Family Medicine, Internal Medicine, or General Surgery.

• Minimum five years of clinical practice beyond residency training.
• Must have experience working in computer systems or EMRs.
• Strong verbal and written communication skills
• Incumbent must maintain state licensure as a board-certified physician by the American Board of Medical Specialties or equivalent entity.
• Incumbent must maintain state licensure as a board-certified physician by the American Board of Medical Specialties.

• Health care payer experience