Per Diem Health Plan UM Medical Director

Mass General Brigham • Somerville, MA

1d • 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 UM Medical Director

Requirements

• MD or DO required
• Physician - Massachusetts active full license required
• 5+ years of Health Plan UM 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
• Use CMS, state and internal medical necessity policies to guide MN determinations
• Complete peer to peer case discussions with requesting providers as assigned
• Refer to IRO/external review if specialist match or expertise is needed
• Interact, communicate and collaborate with network and community physicians, hospital leaders and other vendors regarding care and services for enrollees
• Monitors performance metrics to identify areas for continuous improvement and ensure compliance
• Establishes and maintains positive relationships with colleagues and customers and gains their trust and respect
• Ensure diversity, equity and inclusion are integrated as a guiding principle
• Other duties as assigned with or without accommodation

What This Job Offers

• Career Level: Director
• Education Level: Ph.D. or professional degree