<p>Site: Mass General Brigham Health Plan Holding Company, Inc.</p> <p>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.</p> <p>Job Summary</p> <p>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.</p> <p>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.</p> <p>We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.</p> <p>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.</p> <p>Qualifications</p> <p>Licensure and Credentials:</p> <p>Must maintain an active full physician license in Massachusetts</p> <p>Experience:</p> <ul> <li>3-5 years of Health Plan experience </li><li>at least 5 years of clinical practice experience </li></ul> <p>Job Duties:</p> <p>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</p> <ul> <li>Reviews clinical services and quality incidents when sufficiently serious to merit physician involvement </li><li>Coverage of medical necessity determinations to support special investigations/fraud waste and abuse cases </li><li>Collaborates on health plan medical policy development </li><li>Assesses new, emerging, and existing technologies to determine appropriateness of health plan coverage </li><li>Partners with clinical leaders to ensure medical service expenditures remain within budget </li><li>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 </li><li>Delivers consultation to network management staff and deployment of education programs for network clinicians </li><li>Develops and delivers presentations for clinical staff on current topics relevant to MGB Health Plan members and network </li><li>May represent MGB Health Plan at a variety of external forums and committees </li><li>Interact, communicate and collaborate with network and community physicians, hospital leaders and other vendors regarding care and services for enrollees </li><li>Monitors performance metrics and audits to identify areas for continuous improvement and ensure compliance </li><li>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 </li><li>Build strong relationships and infrastructure that designate MGB Health Plan as a people-first organization </li><li>Ensure diversity, equity and inclusion are integrated as a guiding principle </li><li>Other duties as assigned with or without accommodation </li></ul> <p>Additional Job Details (if applicable)</p> <p>Primarily remote position, exempt</p> <ul> <li>In person meetings as requested for business needs </li><li>Participates in after hours and weekend call rotation as assigned </li></ul> <p>Remote Type</p> <p>Remote</p> <p>Work Location</p> <p>399 Revolution Drive</p> <p>Scheduled Weekly Hours</p> <p>40</p> <p>Employee Type</p> <p>Regular</p> <p>Work Shift</p> <p>Day (United States of America)</p> <p>EEO Statement:</p> <p>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.</p> <p>Mass General Brigham Competency Framework</p> <p>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.</p>