[Hiring] Health Plan Medical Director @Mass General Brigham

Role Description

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.

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
• Other health plan functions

Qualifications

• Physician License: Must hold or be able to obtain a full active Massachusetts physician license.
• 3-5 years of Health Plan experience.
• Prior experience in utilization management and peer-to-peer discussions.
• Collaborates with business development, quality, finance, and medical management teams to promote improvements in the quality and cost efficiency of care throughout Mass General Brigham Health Plan provider network.
• Partners with clinical leaders to ensure medical service expenditures remain within budget.
• Aids in crafting Mass General Brigham Health Plan's clinical programs and policies.
• Collaborates with the CMO in the development and physician oversight of disease management programs.
• Handles initial determinations, appeals, and grievances within the scope of their expertise as defined by MassHealth, Medicare, NCQA, and the Division of Insurance.
• Reviews clinical service and quality incidents when sufficiently serious to merit physician involvement.
• Assesses new, emerging, and existing technologies to determine appropriateness of health plan coverage.
• Supports the clinical, network, and operations staff to ensure end-to-end consistency of clinical policies, payment policies, and claims payment.
• Develops and delivers presentations for clinical staff on current topics relevant to Mass General Brigham Health Plan members and network.
• Administers case and condition consultation to Utilization Management and Care Management staff.
• Delivers consultation to network management staff and deployment of education programs for network clinicians.
• Serves as a member of various Mass General Brigham Health Plan Committees or workgroups.
• May represent Mass General Brigham Health Plan at a variety of external forums and committees.
• Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements.
• Holds self and others accountable to meet commitments.
• Persists in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Builds strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
• Other duties as assigned with or without accommodation.

Requirements

• Virtual position. Full time.
• In-person meetings as requested for business needs.
• Participates in after hours and weekend call rotation as assigned.

Benefits

• Competitive base pay ranging from $285,000.00 to $325,000.00 annually.
• Comprehensive benefits package.
• Career advancement opportunities.
• Differentials, premiums, and bonuses as applicable.
• Recognition programs designed to celebrate contributions and support professional growth.

Company Description

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.