Health Plan Medical Director

Mass General Brigham•Somerville, MA

1d•Remote

About The Position

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated. We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more. Under the direction of the Senior Medical Director, the Medical Director leads as a senior physician at the health plan. This position works closely with the Senior Medical Director in providing medical management leadership for clinical services operations and programs. This role focuses on and has expertise in utilization management, health plan quality and accreditation, care management, and other health plan functions.

Requirements

Must maintain an active full physician license in Massachusetts
3-5 years of Health Plan experience
at least 5 years of clinical practice experience

Responsibilities

Handles utilization management initial determinations, appeals and grievances within the scope of their expertise as defined by Medicare, MassHealth, NCQA and the Division of Insurance and within the compliance requirements of key regulatory and accreditation entities
Reviews clinical services and quality incidents when sufficiently serious to merit physician involvement
Coverage of medical necessity determinations to support special investigations/fraud waste and abuse cases
Collaborates on health plan medical policy development
Assesses new, emerging, and existing technologies to determine appropriateness of health plan coverage
Partners with clinical leaders to ensure medical service expenditures remain within budget
Collaborates with business development, quality, finance and medical management teams to promote improvements in the quality and cost efficiency of care throughout the MGB Health Plan provider network
Delivers consultation to network management staff and deployment of education programs for network clinicians
Develops and delivers presentations for clinical staff on current topics relevant to MGB Health Plan members and network
May represent MGB Health Plan at a variety of external forums and committees
Interact, communicate and collaborate with network and community physicians, hospital leaders and other vendors regarding care and services for enrollees
Monitors performance metrics and audits to identify areas for continuous improvement and ensure compliance
Anticipates and meets or exceeds internal and/or external customer expectations and requirements; establishes and maintains positive relationships with customers and gains their trust and respect
Build strong relationships and infrastructure that designate MGB Health Plan as a people-first organization
Ensure diversity, equity and inclusion are integrated as a guiding principle
Other duties as assigned with or without accommodation