Health Plan Medical Director

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Dec 09, 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. Licensure and Credentials: Must maintain an active full physician license in Massachusetts Experience: 3-5 years of Health Plan experience at least 5 years of clinical practice experience Job Duties: 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 *Participates in after hours and weekend call rotation as assigned 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.