Health Plan Medical Director at Mass General Brigham

Site: Mass General Brigham Health Plan Holding Company Inc.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 SummaryMass General Brigham Health Plan Medical DirectorQualificationsEducation: MD or DO requiredLicenses and Credentials:Physician - Massachusetts active full license requiredExperience:3-5 years of Health Plan experienceat least 5 years of clinical practice experienceKnowledge Skills and Abilities:Utilization Management experienceExcellent written and oral communications skillsProficient in basic computer skills use of EHRs digital toolsMultitasking abilitiesAdaptable to change due to business growthJob 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 entitiesReviews clinical services and quality incidents when sufficiently serious to merit physician involvementCoverage of medical necessity determinations to support special investigations/fraud waste and abuse casesCollaborates on health plan medical policy developmentAssesses new emerging and existing technologies to determine appropriateness of health plan coveragePartners with clinical leaders to ensure medical service expenditures remain within budgetCollaborates 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 networkDelivers consultation to network management staff and deployment of education programs for network cliniciansDevelops and delivers presentations for clinical staff on current topics relevant to MGB Health Plan members and networkMay represent MGB Health Plan at a variety of external forums and committeesInteract communicate and collaborate with network and community physicians hospital leaders and other vendors regarding care and services for enrolleesMonitors performance metrics and audits to identify areas for continuous improvement and ensure complianceAnticipates and meets or exceeds internal and/or external customer expectations and requirements; establishes and maintains positive relationships with customers and gains their trust and respectBuild strong relationships and infrastructure that designate MGB Health Plan as a people-first organizationEnsure diversity equity and inclusion are integrated as a guiding principleOther duties as assigned with or without accommodationAdditional Job Details (if applicable)Primarily remote position exemptIn person meetings as requested for business needsM-F 830-5pm EST; Participates in after hours and weekend call rotation as assignedEnsures that all assigned work is completed within regulatory timelinesChecks and addresses assigned work queues email Teams messages during assigned work hoursRemote TypeRemoteWork Location399 Revolution DriveScheduled Weekly Hours40Employee TypeRegularWork ShiftDay (United States of America)EEO Statement: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 Veterans 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 .Mass General Brigham Competency FrameworkAt 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.Required Experience:Director Key Skills EMR Systems,Post Residency Experience,Occupational Health Experience,Clinical Research,Managed Care,Primary Care Experience,Medical Management,Utilization Management,Clinical Development,Clinical Trials,Leadership Experience,Medicare Employment Type : Full-Time Experience: years Vacancy: 1 Monthly Salary Salary: 285000 - 325000