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.

The salary range for this position is $285,000.00 to $325,000.00 annually. At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will consider your skills, relevant experience, if applicable, education, certifications, and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package.
In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums, and bonuses as applicable, and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

Job Summary

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.

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.

Qualifications Licenses and Credentials

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

Needs 3-5 years of Health Plan experience

• Must have prior experience in utilization management, peer to peer discussions
• 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 Mass Health, 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.
• 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.

Additional Job Details (if applicable)

Virtual position. Full time.

In person meetings as requested for business needs.

Participates in after hours and weekend call rotation as assigned.

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

EEO Statement:

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 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.

Mass General Brigham Competency Framework

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.