Medical Director

WellSense Health Plan•Boston, MA

8d•$173,000 - $250,000•Remote

About The Position

The Medical Director will report to the Senior Medical Director of Utilization Management, Member Appeals & Grievances, and Medical Policy (Senior Medical Director of Utilization Management) and support the staff of the Office of Clinical Affairs in the areas of medical management daily medical necessity reviews, evaluation of medical policy, utilization trend management, quality, appeals and grievances, and pharmacy reviews.

Requirements

Graduate as a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) from an accredited allopathic or osteopathic medical school
8-10+ years of related experience is required including a minimum of 5 years direct clinical experience and a minimum of 3 years experience in medical management in a managed care setting
Active or lifetime board certification in recognized medical specialty of the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA)
Current unrestricted licensure as an MD or DO in Massachusetts and New Hampshire is required, or ability to obtain in a reasonable timeframe
No restriction on participation in Medicare or Medicaid programs
Excellent demonstrated clinical skills and knowledge
Excellent written and verbal communication skills.
Comprehensive knowledge of accrediting organizations such as NCQA.
Comprehensive knowledge of InterQual protocols, HEDIS, and other quality measures.
Knowledge of Medicare and state Medicaid regulations, guidelines, and standards.
Proven leadership skills and relationship building.
Knowledge of managed care principles and processes.
Ability to work independently with intermittent supervision.
Adhere to appropriate turn-around-times and deadlines while maintain results of high quality and reliability.

Nice To Haves

Board Certification in Internal Medicine
Board Certification in Internal Medicine-Pediatrics (Med Peds)
Board Certification in Family Medicine
Board Certification in Emergency Medicine
Current unrestricted licensure as an MD in Massachusetts or New Hampshire is preferred

Responsibilities

Provides clinical case review, consultation and oversight for all utilization management activities in a fashion that is compliant with all federal, state, and NCQA requirements
Conducts review of prior authorizations, concurrent reviews and retrospective medical necessity reviews that do not meet standard criteria and determines coverage
Works with the Senior Medical Director of Utilization Management to identify appropriate use of InterQual criteria and Medical Policy
Works with the Senior Medical Director to ensure consistent medical decision making for all physician reviewers, including the contracted physicians
Conducts clinical review of appeals and grievances in a fashion that is compliant with all federal, state and NCQA requirements
Develops and supports clinical initiatives to support department quality improvement and utilization management goals
Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
Collaborates with hospital physicians, medical directors, primary care physicians and nurse case managers in daily activities and initiatives to improve the health of the population, the quality and experience of care our members receive, and lower the overall cost of care at the population level
Participates in and chairs clinical committees as assigned by the Senior Medical Director of Utilization Management
Supports quality, and pharmacy committees and activities
Provides input to the strategic planning process for the Office of Clinical Affairs as requested
Represents the Chief Medical Officer or Senior Medical Directors in Massachusetts, New Hampshire and other locations as requested