Medical Director, Medicare and Special Investigations Unit
3 weeks ago
We are seeking a highly skilled and experienced Medical Director to lead our Medicare and Special Investigations Unit. The successful candidate will be responsible for providing clinical oversight and leadership for the Medicare Advantage line of business, as well as overseeing clinical review and responsibilities for the Special Investigation Unit.
Key Responsibilities- Provide clinical oversight and leadership for the Medicare Advantage line of business, including developing and implementing strategies to ensure appropriate, cost-effective, efficient care for Medicare Advantage and other lines of business.
- Act as expert medical advisor for Medicare-related activities, including providing clinical oversight and leadership for the Medicare Advantage Utilization Management (UM) Committee, meeting all CMS requirements.
- Oversee clinical review and responsibilities for the Special Investigation Unit, including providing 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, 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, and author reports summarizing clinical findings relative to FWA investigative audit activity.
- 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.
- Demonstrate Mass General Brigham Health Plan's 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.
- 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.
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Somerville, Massachusetts, United States Mass General Brigham Full timeJob Title: Medical Director, Medicare and Special Investigations UnitMass General Brigham Health Plan is seeking a highly skilled Medical Director to lead our Medicare and Special Investigations Unit. As a key member of our leadership team, you will be responsible for providing clinical oversight and leadership for our Medicare Advantage line of business.Key...
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Somerville, Massachusetts, United States Mass General Brigham Full timeJob SummaryWe 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 is a hybrid role with occasional onsite team meetings in Somerville, MA.Key...
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