Medical Director, Medicare and Special Investigations Unit

3 weeks ago


Somerville, Massachusetts, United States Mass General Brigham Health Plan Full time
Job Summary

We are seeking a highly skilled Medical Director to lead our Medicare and Special Investigations Unit. As a key member of our team, you will be responsible for providing clinical oversight and leadership for our Medicare Advantage line of business. This role requires a strong understanding of healthcare systems, providers, and insurance billing and coding standards.

Key Responsibilities:

  • 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 policies 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 to fraud, waste, and abuse (FWA) and reviewing and analyzing information to draw conclusions on allegations of FWA and/or determine appropriateness of care
  • Perform Peer-to-Peer outreach functions in support of the Plan's Medicare Advantage Drug Management Program
  • Investigate and review medical records and support SIU and regulatory communications
  • 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

Requirements:

  • 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 the 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

What We Offer:

  • Competitive salaries
  • Benefits package with flexible work options
  • Career growth opportunities
  • Opportunity to work with a leading healthcare system


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