Mass General Brigham
The role involves managing utilization management determinations, appeals, and grievances in compliance with Medicare, MassHealth, NCQA, and other regulatory requirements. The Medical Director will collaborate with providers, hospital leaders, and vendors to ensure appropriate care and services for enrollees while monitoring performance metrics for continuous improvement.
Key Responsibilities
- • 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
- • Ensures that all assigned work is completed within regulatory timelines
- • Checks and addresses assigned work queues, email, Teams messages during assigned work hours
Required
- • MD or DO required
- • Physician - Massachusetts active full license required
- • 5+ years of Health Plan UM experience
- • at least 5 years of clinical practice experience
- • 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
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
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
EEO Statement:
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.
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