Health Plan Medical Director
- 2410 Brigham and Women's Physicians Organization, Inc.
- Somerville-MA
- 5mo ago
- Full-Time
- Remote
...
Site: Mass General Brigham Health Plan Holding Company, Inc.Remote399 Revolution Drive40RegularDay (United States of America)Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.
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
Qualifications
Education: MD or DO required
Licenses and Credentials:
- Physician - Massachusetts active full license required
Experience:
- 3-5 years of Health Plan experience
- at least 5 years of clinical practice experience
Knowledge, Skills and Abilities:
- 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
Job Description:
- 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
Additional Job Details (if applicable)
- Primarily remote position, exempt
- In person meetings as requested for business needs
- M-F 830-5pm EST; Participates in after hours and weekend call rotation as assigned
- Ensures that all assigned work is completed within regulatory timelines
- Checks and addresses assigned work queues, email, Teams messages during assigned work hours
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.