Health Plan Medical Director
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Job Location:
Somerville, NJ - USA
Monthly Salary:
USD 285000 - 325000
Posted on:
30+ days ago
Vacancies:
1 Vacancy
Job Summary
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 DirectorQualifications
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 EHRs 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.
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
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
