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Job Summary:

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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 high0quality, cost0effective 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 peer0to0peer discussions. Ensure determinations are clinically sound and timely.
• Oversee grievance and appeals clinical reviews and author evidence0based 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., HEDIS0aligned 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 value0based models, performance feedback, appeals resolution themes, and market growth priorities.

Cross0functional 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 plan0s 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 MCO0s and appropriately manages information shared between organizations

Minimum Qualifications (Required)

• MD or DO, board certified (ABMS/AOA).
• Active Pennsylvania medical licenseoreligibility to obtain PA licensure within6 monthsof hire.
• 5 67+ yearsclinical practice plus3+ yearsin a health0plan medical leadership role (Medical Director or Deputy)specific to Medicaid(multi 2state plan experience required 6e.g., oversight in at least one additional state or a regional program).
• Demonstrated experience withutilization management, appeals/grievances, and medical policyin a managed care setting.
• Working knowledge ofNCQA/URACstandards andstate Medicaidregulatory 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 inpopulation health,value0based payment,behavioral health integration, andLTSS.
• Preferred Certification: Certified Professional in Healthcare Quality (CPHQ). Or obtain upon hire within the first year of employment.
• Familiarity withInterQual/MCGcriteria and care management platforms; comfort using data to guide clinical operations and provider performance.

Core Competencies

• Evidence0based decision0making; 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:

Position Details:

Location: Pennsylvania (onsite/hybrid/remote with periodic in0state 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