Health Plan Medical Director

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Mar 07, 2025
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. Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated. We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more. 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, and other health plan functions. Licenses and Credentials Physician License for Massachusetts or willing to get license. Administrative license acceptable. Needs 3-5 years of Health Plan experience 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 and within the compliance requirements of key regulatory and accreditation entities. 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 the following Mass General Brigham Health Plan Committees or workgroups: Clinical Policy & Quality, Patient Care Assessment, Credentialing, Utilization Management, Medical Economics and Behavioral Health Oversight. 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; establishes and maintains positive relationships with customers and gains their trust and respect. Hold self and others accountable to meet commitments. Ensure diversity, equity, and inclusion are integrated as a guiding principle. Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise. Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization. Other duties as assigned with or without accommodation. Virtual position. Full time. Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.