Per Diem Health Plan UM Medical Director

Mass General Brigham Health Plan UM Medical Director Education: MD or DO required Licenses and Credentials: Physician - Massachusetts active full license required Experience: 5+ years of Health Plan UM experienceat least 5 years of clinical practice experience Knowledge, Skills and Abilities: Utilization Management experienceExcellent written and oral communications skillsProficient in basic computer skills, use of EHR's, digital toolsMultitasking abilitiesAdaptable 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 Remote Position Details Primarily remote position M-F 8:30‑5:00 pm EST Ensures that all assigned work is completed within regulatory timelines Checks and addresses assigned work queues, email, Teams messages during assigned work hours Mass General Brigham Incorporated 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. #J-18808-Ljbffr