Senior Medical Director, Health Plan

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 Summary

The Senior Medical Director serves as a key clinical executive within the health plan providing strategic leadership medical oversight and clinical expertise to ensure highquality costeffective 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 valuebased care initiatives. The Senior Medical Director represents the health plan externally with providers regulators and community partners.


Does this position require Patient Care
Yes

Essential Function:

• 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 valuebased care models.
• Serve as a clinical advisor to senior executives and crossfunctional teams.
• Oversee utilization management (UM) programs ensuring evidencebased timely and compliant decisionmaking.
• 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 valuebased contracting and engage with physicians and health systems to promote evidencebased 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 uptodate 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 decisionmaking.

Education:
Doctorate Related Field of Study required

Can this role accept experience in lieu of a degree
No

Licenses and Credentials

Physician License. Must hold or be able to obtain a full active Massachusetts physician license.

Must have 3-5 years of Health Plan experience

• Must have prior experience in utilization management peer to peer discussions

Experience:
Clinical Experience 8-10 years required and Experience in managed care health plan or population health leadership role 5-7 years required

Knowledge Skills and Abilities:

• Strategic thinking and clinical judgment
• Executive communication and influence
• Datadriven decisionmaking
• Collaborative leadership
• Regulatory and compliance awareness
• Provider engagement and relationshipbuilding

Salary Range:

$320 - $350K (depending upon experience)

Remote

399 Revolution Drive

40

Regular

Day (United States of America)

8925 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 .