Health Plan Medical Director

Brigham and Women's Hospital•Somerville, MA

38d•Remote

About The Position

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary Mass General Brigham Health Plan Medical Director

Requirements

MD or DO required
Physician - Massachusetts active full license required
3-5 years of Health Plan experience
at least 5 years of clinical practice experience
Utilization Management experience
Excellent written and oral communications skills
Proficient in basic computer skills, use of EHR's, digital tools
Multitasking abilities
Adaptable to change due to business growth

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
Ensures that all assigned work is completed within regulatory timelines
Checks and addresses assigned work queues, email, Teams messages during assigned work hours