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