GEHA (Government Employees Health Association, Inc., pronounced G.E.H.A.) is a nonprofit member association that provides medical and dental benefits to over two million federal employees, retirees, military retirees, and their families. We celebrate diversity and are committed to creating an inclusive environment for all employees. At GEHA, our mission is clear: to empower federal workers to be healthy and well. We pride ourselves on one of the largest medical and dental benefit provider networks available to federal employees in the United States, ensuring that we meet our members where they are—when they need care. Our aim is to deliver valued products and a personalized customer experience sustained by efficient organizational capabilities. As the National Medical Director, you will play a critical role in advancing care delivery, enhancing cost containment, and driving quality improvements. This key position involves clinical review of escalated claims and appeals, managing third-party vendor relationships, performance evaluations, and collaborating on enterprise-wide clinical strategies. We are looking for a leader who exemplifies professionalism and has a strong capacity for teamwork across both clinical and non-clinical settings. Duties and Responsibilities: Conduct thorough reviews of medical and pharmacy cases to ensure compliance with evidence-based medicine standards and GEHA clinical programs, documenting rationales and collaborating effectively with team members. Ensure clinical decisions align with plan documents, aiding clinical staff in proper interpretations regarding clinical services. Provide guidance and support for escalated clinical cases and assist clinical and pharmacy staff with urgent decisions. Evaluate the need for external reviews of medical or pharmacy cases, ensuring high-quality assessments from external review organizations. Develop and refine internal guidelines to streamline review processes, ensuring consistent application by clinical and pharmacy teams. Mitigate risk for GEHA by collecting relevant medical data and applying clinical judgments on unique or questionable claims. Collaborate with Quality, Medical Management, Strategic Business Insights (SBI), and Care Management teams to facilitate the success of clinical programs. Act as the primary medical authority for both clinical and non-clinical teams, working with staff to develop cost-effective strategies that meet member needs within plan parameters. Contribute to the development and update of claims payment policies, ensuring proper coding aligned with preventive guidelines. Provide ongoing medical support to external partners and GEHA staff involved in clinical program execution. Assist the Special Investigations Unit in reviewing cases with utilization management concerns, making determinations on medical necessity and participating in the appeals process as required. Support the configuration and continual review of clinical edits to minimize inappropriate payments or overpayments. Knowledge, Skills, and Abilities: Doctor of Medicine degree from an accredited institution. Current, unrestricted medical license with evidence of completing necessary continuing medical education (CME) credits. Board certification in Family Medicine, Internal Medicine, or General Surgery. A minimum of five years of clinical experience beyond residency. Experience working with computer systems or electronic medical records (EMRs). Excellent verbal and written communication skills. Maintaining state licensure as a board-certified physician through the American Board of Medical Specialties or a comparable governing body. Preferred Qualifications Experience in health care payer sectors. Work-at-home Requirements: Must provide a reliable high-speed internet connection, such as Fiber, DSL, or cable, for a home office, with a minimum performance standard of 30mbps download and 5mbps upload. Latency response time below 80 ms is required. Hotspots, satellite, and wireless internet services are not acceptable for this role. A dedicated workspace free of interruptions is essential to protect member PHI/HIPAA information. How We Value You: Competitive salary and incentive plans. Health/Vision/Dental benefits commencing on the first day of employment. 401(k) retirement plan with a dollar-for-dollar match up to 4% of employee contributions and a 6% annual contribution from the company. Robust employee well-being program and paid time off. Company-provided Basic Life and Accidental Death & Dismemberment (AD&D) insurance, as well as Short-Term and Long-Term Disability coverage. Tuition Assistance Program. GEHA is an equal opportunity employer and will not discriminate based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, or sexual orientation, and other protected statuses. Our commitment to inclusivity drives our organizational strength and innovation. GEHA's headquarters is located in Lee's Summit, Missouri, near Kansas City. We value balance and offer both hybrid and remote work options for many roles.