Mass General Brigham Health Plan
Medical Director for Health Plans
Mass General Brigham Health Plan, Cleveland, Ohio, us, 44101
Join the dynamic team at Mass General Brigham Health Plan, where we are revolutionizing the healthcare landscape as part of a premier integrated healthcare system. Our commitment to innovative solutions that prioritize member health and improve access to seamless and affordable care sets us apart. We value our employees, offering competitive salaries, a comprehensive benefits package, and flexible work options, as well as opportunities for career growth.
As the Medical Director, you will play a vital role in leading medical management initiatives under the guidance of the Senior Medical Director. Your expertise will be crucial in optimizing utilization management, enhancing health plan quality and accreditation, and overseeing comprehensive care management functions.
Key Responsibilities:
Collaborate with cross-functional teams—including business development, quality, finance, and medical management—to enhance the quality and cost-effectiveness of care within the Mass General Brigham Health Plan provider network. Partner with clinical leaders to ensure medical expenditures align with budget goals. Contribute to the development of clinical programs and policies that reflect our commitment to excellence. Work alongside the CMO to oversee the implementation of disease management programs. Manage initial determinations, appeals, and grievances, ensuring compliance with regulatory and accreditation standards. Review significant clinical service and quality incidents that require physician involvement. Evaluate new and emerging technologies to guide health plan coverage decisions. Support clinical, network, and operations teams to ensure consistency in clinical policies and claims payment processes. Develop and deliver engaging presentations for clinical staff on topics vital to Mass General Brigham Health Plan members and network. Provide expert consultation to Utilization Management and Care Management staff. Deliver educational programs for network clinicians, enhancing collaboration and understanding. Participate as a member of key Mass General Brigham Health Plan committees focusing on clinical policy, quality, credentialing, utilization management, and more. Represent the health plan in external forums and committees. Exceed internal and external customer expectations, building trust and positive relationships. Stay accountable to commitments and consistently work towards achieving organizational objectives. Foster a people-first culture, establishing strong relationships to enhance our organizational structure. Other duties as assigned. This is a full-time virtual position. Licenses and Credentials:
Must hold a Physician License for Massachusetts or be willing to obtain one; administrative licenses are also acceptable. Requires 3-5 years of health plan experience. Qualifications and Preferences:
Experience with Dual Eligible Special Needs Plan (DSNP) or Senior Care Options, Medicare, and Medicaid populations is essential. Expertise in utilization management and care management strategies for complex member populations. Experience in mental health parity is advantageous. Familiarity with HEDITS/STARTS processes is a plus. A background in quality improvement is preferred. Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. We embrace diverse skills, perspectives, and ideas to drive our leadership in the field. All qualified applicants will be considered for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, or any other status protected under the law. We will provide reasonable accommodations for individuals with disabilities to participate fully in the application and interview processes, perform essential job functions, and receive benefits and privileges of employment.
Collaborate with cross-functional teams—including business development, quality, finance, and medical management—to enhance the quality and cost-effectiveness of care within the Mass General Brigham Health Plan provider network. Partner with clinical leaders to ensure medical expenditures align with budget goals. Contribute to the development of clinical programs and policies that reflect our commitment to excellence. Work alongside the CMO to oversee the implementation of disease management programs. Manage initial determinations, appeals, and grievances, ensuring compliance with regulatory and accreditation standards. Review significant clinical service and quality incidents that require physician involvement. Evaluate new and emerging technologies to guide health plan coverage decisions. Support clinical, network, and operations teams to ensure consistency in clinical policies and claims payment processes. Develop and deliver engaging presentations for clinical staff on topics vital to Mass General Brigham Health Plan members and network. Provide expert consultation to Utilization Management and Care Management staff. Deliver educational programs for network clinicians, enhancing collaboration and understanding. Participate as a member of key Mass General Brigham Health Plan committees focusing on clinical policy, quality, credentialing, utilization management, and more. Represent the health plan in external forums and committees. Exceed internal and external customer expectations, building trust and positive relationships. Stay accountable to commitments and consistently work towards achieving organizational objectives. Foster a people-first culture, establishing strong relationships to enhance our organizational structure. Other duties as assigned. This is a full-time virtual position. Licenses and Credentials:
Must hold a Physician License for Massachusetts or be willing to obtain one; administrative licenses are also acceptable. Requires 3-5 years of health plan experience. Qualifications and Preferences:
Experience with Dual Eligible Special Needs Plan (DSNP) or Senior Care Options, Medicare, and Medicaid populations is essential. Expertise in utilization management and care management strategies for complex member populations. Experience in mental health parity is advantageous. Familiarity with HEDITS/STARTS processes is a plus. A background in quality improvement is preferred. Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. We embrace diverse skills, perspectives, and ideas to drive our leadership in the field. All qualified applicants will be considered for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, or any other status protected under the law. We will provide reasonable accommodations for individuals with disabilities to participate fully in the application and interview processes, perform essential job functions, and receive benefits and privileges of employment.