Medical Director
Company: Brigham and Women's Hospital
Location: Somerville
Posted on: March 15, 2023
Job Description:
Job Description - Medical Director (3224327) Medical Director -
( 3224327 ) 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. Mass General Brigham Health
Plan is seeking a physician leader for the health plan. The Medical
Director of Medical Policy and Utilization Management will work
with the Deputy CMO and other medical directors in providing
medical management leadership for clinical services operations and
programs. Specific focus on utilization management to ensure to
ensure the appropriate and most cost-effective medical care is
received. - Essential Functions Individual will provide leadership
and oversight in the development and annual review of medical
necessity policies including being the Chair of the Medical Policy
Committee. Will need to possess a high level of proficiency in
analyzing the medical literature and proven skills in synthesis and
integration of information from multiple resources
- Requires a solid understanding of research study design and
quality of clinical evidence to provide guidance for the medical
policy process
- Evaluates requests for service coverage for medical necessity
through collaboration with Utilization Management staff.
- Conduct peer clinical and/ or appeal case reviews and
peer-to-peer clinical reviews with attending physicians or other
ordering providers to discuss review determinations, provides
guidance for clinical operational aspects of the program.
- Support quality accreditation requirements (e.g., NCQA; CMS,
EOHHS) for medical policy, including the integration of clinical
input on medical criteria from participating network providers
- Collaborates with cross functional teams to make decisions
regarding benefits coverage based on medical evidence
- Remain up-to-date on new developments at the intersection of
science, technology, analytics and business to drive clinical
innovation and policy transformation. Assesses these new, emerging
and existing technologies to determine the appropriateness of
health plan coverage.
- Working collaboratively with UM leadership in including the
Director of UM in the following areas analyzing data regarding UM
to explore opportunities to improve UM processes and improving
provider experience with the health plan
- Supports medical trend management process for areas related to
utilization management
- Monitor healthcare trends in the pipeline management of new
Medical Policies
- Supports the medical management staff ensuring timely and
consistent responses to members and providers.
- Serves as a resource and consultant to other areas of the
company, may serve on company committees, may be required to
represent the company to external entities and/or serve on external
committees.
- Anticipates and meets, or exceeds, internal and/or external
customer expectations and requirements; establishes and maintains
effective relationships with customers and gains their trust and
respect. Supervisory Responsibility
- Responsible to hire, to participate in and recommend
development measures and disciplinary actions up to and including
termination, to evaluate performance, and to supervise the work of
all direct and indirect reports following established
organizational policies, procedures, and practices Working
Conditions and Physical Effort Work is normally performed in a
hybrid or remote work environment. Knowledge and Education
- MD or DO and Board certification approved by one of the
following certifying boards is required, where applicable to duties
being performed, American Board of Medical Specialties (ABMS),
American Osteopathic Association (AOA) or National Board of
Physicians and Surgeons (NBPAS).
- Valid unrestricted Massachusetts medical license. Experience
- 5 (plus) years of clinical practice experience
- 3 (plus) years of medical management or comparable
policy/utilization review experience preferred with at least 1 year
of experience in medical policy leadership with a managed care
organization
- Demonstrated ability to utilize data and analytics to support
medical and policy decision making. Incumbent/Candidate Profile:
Skills/Competencies (preferred) -
- Demonstrate MGB Health Plan's core brand principles of always
listening, challenging conventions, and providing value.
- Ability to translate and communicate complex topics in a
variety of forums, tailoring communications to effectively fit and
influence the targeted audience is a requirement of this
position.
- Individual must have strong executive presence, presentation,
and communication skills. Strong verbal, active listening, and
written communication skills required. -
- Strong commitment to diversity, equity and inclusion
- Strong, demonstrated track record of an ability to execute on
time, on budget, and on scope.
- Strong aptitude for technology-based solutions.
- Excellent leadership skills and leadership track record.
- Excellent interpersonal skills, including the ability to
influence others at all levels of an organization. -
- Strong EQ; exercises self-awareness; monitors impact on others;
is receptive to and seeks out feedback; uses self-discipline to
adjust to feedback.
- Excellent organizational and analytical skills. -
- Excellent judgment and decision-making abilities.
- Strong influencing skills and perseverance
- Ability to develop and motivate employees to meet departmental
and organizational objectives.
- Ability to manage multiple projects, meet deadlines and nimbly
-adjust to changes in company policies, procedures and priorities .
Mass General Brigham 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. Primary Location MA-Somerville-MGB Health Plan at
Assembly Row Work Locations MGB Health Plan at Assembly Row Job
MD/PHD/Fellows/ PostDocs Organization Mass General Brigham Health
Plan Schedule Part-time Standard Hours 32 Shift Day Job Employee
Status Regular Recruiting Department MGB Health Plan Clinical
Keywords: Brigham and Women's Hospital, Somerville , Medical Director, Executive , Somerville, Massachusetts
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