Senior Medical Director, Health Plan

Mass General Brigham•Somerville, MA

4d•$320,000 - $350,000•Remote

About The Position

The Senior Medical Director serves as a key clinical executive within the health plan, providing strategic leadership, medical oversight, and clinical expertise to ensure high‑quality, cost‑effective care for members. This role partners closely with executive leadership, clinical operations, network management, quality, and compliance teams to shape clinical strategy, guide utilization management, and support value‑based care initiatives. The Senior Medical Director represents the health plan externally with providers, regulators, and community partners.

Requirements

Doctorate Related Field of Study required
Physician [State License] - Generic - HR Only required
Clinical Experience 8-10+ years required
Experience in managed care, health plan, or population health leadership role 5-7 years required
Strategic thinking and clinical judgment
Executive communication and influence
Data‑driven decision‑making
Collaborative leadership
Regulatory and compliance awareness
Provider engagement and relationship‑building

Responsibilities

Develop and execute clinical strategies that improve member outcomes, reduce unnecessary utilization, and support organizational goals and provide medical expertise to guide benefit design, population health programs, and value‑based care models.
Serve as a clinical advisor to senior executives and cross‑functional teams.
Oversee utilization management (UM) programs, ensuring evidence‑based, timely, and compliant decision‑making.
Review complex or escalated cases, appeals, and grievances, and ensure UM policies align with regulatory requirements, accreditation standards, and clinical best practices.
Lead quality improvement initiatives, including HEDIS, Stars, NCQA, and other performance programs, and partner with analytics teams to identify trends in utilization, quality, and member health outcomes.
Support the development of population health programs targeting chronic disease management, behavioral health, and social determinants of health.
Collaborate with provider network teams to improve clinical performance, reduce variation, and support value‑based contracting, and engage with physicians and health systems to promote evidence‑based care and address performance issues.
Represent the health plan in provider forums, committees, and external meetings.
Ensure clinical programs comply with federal and state regulations, accreditation standards, and internal policies, and participate in audits, regulatory reviews, and accreditation activities.
Maintain up‑to‑date knowledge of evolving healthcare regulations and clinical guidelines.
Partner with behavioral health, pharmacy, care management, and social care teams to coordinate integrated care strategies.
Provide medical leadership for product development, member engagement initiatives, and clinical innovation projects, and support executive leadership with clinical insights for strategic planning and organizational decision‑making.