Medical Director, Medicare And Special Investigations Unit

This is a hybrid role with occasional (roughly 1x/every other month) onsite team meetings in Somerville, MA.

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.

The Medical Director, Medicare Advantage Focused, will work closely with Senior Medical Director and Medical Director team to improve focus and execution in the Clinical department with activities related to all lines of business, but with a primary focus on our Medicare Advantage plans. This full time medical director will also take the physician lead for activities related to fraud , waste and abuse concerns reviewed in conjunction with our Special Investigation Unit.

Principal Duties and Responsibilities

Act as expert medical advisor for Medicare related activities:

• Provide Clinical oversight and leadership for the Medicare Advantage line of business

• Lead the Medicare Advantage Utilization Management (UM) Committee, meeting all CMS requirements

• Assist with the development and implementation of strategies to ensure appropriate, cost-effective, efficient care for Medicare Advantage and other lines of business

• Act as physician leader for the Plan for all Medicare Advantage quality management functions: analyze information to develop interventions that improve quality of care and outcomes, with a focus on at risk performance (ex: STARS, State-based programs, VBC)

• Develop and deliver presentations for Mass General Brigham Health Plan Clinical staff on current topics relevant to Medicare Advantage

• Provide expert consultation for Medicare Advantage compliance activities including audit activities and lead clinical oversight of delegated entities

• Work with relevant business areas on plan polices and operations related to Medicare Advantage benefits and claims management

Oversee clinical review/responsibilities for the Special Investigation Unit:

• Provide Clinical oversight and lead clinical support for Special Investigation Unit reviews as related to all lines of business to include clinical documentation and claims data review

• Work in collaboration with the Legal, Regulatory and Compliance staff to identify trends and/or practice concerns related fraud, waste and abuse (FWA) and reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care

• Perform Peer-to-Peer outreach functions in support of the Plan's Medicare Advantage Drug Management Program

• Execute a comprehensive analysis and clinical evaluation of each case, enlisting specialty input as needed

• Author reports summarizing clinical findings relative to FWA investigative audit activity

Perform medical director responsibilities in a best-in-class manner:

• Execute medical management decisions in a timely fashion meeting all regulatory requirements for all lines of business (Medicare Advantage/Commercial/Medicaid/ASO) in terms of utilization management and appeal case reviews

• Handle initial determinations, appeals and grievances within the scope of expertise as defined by MassHealth, Medicare, NCQA and the Division of Insurance and within the compliance requirements of key regulatory and accreditation entities

• Participate in and performance of reviews regarding quality of care concerns/grievances and special investigation unit concerns pertaining to fraud, waste and abuse when sufficiently serious to merit physician involvement

• In conjunction with the Medical Director team, review and implement utilization management and medical policy, including recommendations for improvements to enhance efficiency

• Partake in the assessment of new, emerging, and existing technologies to determine appropriateness of health plan coverage

• Work in collaboration with UM and Care Management (CM) teams to understand utilization of services and develop and implement programs to address inappropriate utilization and readmissions

• Support and uphold regulatory requirements, compliance, policies and contractual agreements, and address/mitigate risk

• Work within the Plan and with network providers on value-based initiatives, quality, and provider satisfaction; supports providers to align performance with plan goals

• Support the clinical, network, and operations staff to ensure end to end consistency of clinical policies, payment policies and claims payment

• Serves as a member of Mass General Brigham Health Plan Committees or workgroups

• Supports new market entry and implementations

Foster collaborative relationships with customers and stakeholders

• Provide leadership and oversight in a way that promotes a supportive, respectful environment

• Develop effective relationships with leaders and staff in the Health Plan

• Present ideas, updates, findings, reports, recommendations, data, and analysis to various audiences to build consensus on program initiatives

Use Mass General Brigham healthcare values to govern decisions, actions, and behaviors

• These values govern how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration

• Motivates and encourages staff; leads through change and adversity. Makes decisions as needed and builds consensus as appropriate.

• Communicates and cascades information to employees in a timely manner and actively participates in the success of cross-organizational programs and initiatives.

• Inform, engage, inspire, motivate, and actively listen to employees.

• Make decisions that put the needs of the people we serve-our members, providers, brokers, and employers-front and center.

• Communicate and cascade information to employees in a timely manner and actively participate in the success of cross-organizational programs and initiatives.

• Identify/create processes and align resources to accomplish key objectives; clearly convey and assign clear accountability for important objectives, deadlines, and expectations.

• Ensure diversity, equity, and inclusion are integrated as a guiding principle.

Qualifications

• Medical Doctor degree required with board eligibility in internal medicine or family practice and 5 years of clinical practice experience including the care of patients age over 65; 2 years of medical management or comparable policy/utilization review experience and must be considered actively practicing

• 3-5 years minimum experience working in a health plan with direct Medicare Advantage responsibilities

• Experience with dual eligible programs a plus

• Valid unrestricted Massachusetts Medical Doctor license required

• Must be clear of any sanctions by the State of Massachusetts and Office of the Inspector General

• Deep understanding of healthcare systems, providers, health insurance drivers, and insurance billing and coding standards

• Proven ability to apply data and analytics to support medical and policy decision making

Skills, Abilities and Competencies

• Demonstrate Mass General Brigham Health Plans core brand principles of always listening, challenging conventions, and providing value.

• Bring fresh ideas forward by listening to and working with employees and the people we serve.

• Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner.

• Strong, demonstrated track record of an ability to execute on time, on budget, and on scope.

• Strong aptitude for technology-based solutions.

• Ability to inject energy, when and where it's needed.

• Current in healthcare trends.

• Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be."

• Ability to develop, introduce, defend, and gain support for a new ideas and approaches.

• Excellent leadership skills and leadership track record.

• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills. Strong verbal, active listening, and written communication skills required.

• Ability to view the long-range trends and cycles of the business and industry and see the "big picture."

• Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.

• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.

• 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.

• Unquestionable integrity.

• Demonstrates fiscal responsibility by effectively using Mass General Brigham Health Plan resources

• Primarily Remote with occasional on-site meeting attendance