Health Plan Medical Director

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 EHR's, 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

• 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