Per Diem Health Plan UM Medical Director

Site: Mass General Brigham Incorporated

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.

Job Summary

Mass General Brigham Health Plan UM Medical Director

Qualifications

Education: MD or DO required

Licenses And Credentials

• Physician - Massachusetts active full license required

Experience

• 5+ years of Health Plan UM 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
• Use CMS, state and internal medical necessity policies to guide MN determinations
• Complete peer to peer case discussions with requesting providers as assigned
• Refer to IRO/external review if specialist match or expertise is needed
• Interact, communicate and collaborate with network and community physicians, hospital leaders and other vendors regarding care and services for enrollees
• Monitors performance metrics to identify areas for continuous improvement and ensure compliance
• Establishes and maintains positive relationships with colleagues and customers and gains their trust and respect
• Ensure diversity, equity and inclusion are integrated as a guiding principle

Other duties as assigned with or without accommodation

Additional Job Details (if Applicable)

• Primarily remote position
• M-F 830-5pm EST
• Ensures that all assigned work is completed within regulatory timelines
• Checks and addresses assigned work queues, email, Teams messages during assigned work hours

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

0

Employee Type

Regular

Work Shift

Day (United States of America)

EEO Statement

Balance Sheet Cost Centers 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.