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Medical Director, Medicare and Special Investigations Unit
2 months ago
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 is a hybrid role with occasional onsite team meetings in Somerville, MA.
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, including 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
- 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
- Normal office working conditions
- Primarily Remote with occasional on-site meeting attendance
MD/PHD/Fellows/PostDocs
OrganizationMass General Brigham Health Plan
ScheduleFull-time
ShiftDay Job
