Overview
The Senior Medical Director for Medical Management will lead medical management strategy and operations for the MassHealth Office of Clinical Affairs to ensure the delivery of medically necessary, cost-effective, and high quality care for MassHealth members. Working closely with clinical and operational leaders within the Office of Clinical Affairs, this leader will oversee program initiatives related to utilization management (including prior authorizations), medical coverage policy, and care management.
Responsibilities
Medical Management Strategy and Policy
โข Leads development and implementation of Office of Clinical Affairs strategy for medical management to ensure appropriate, efficient, and high quality care delivery
โข Collects, analyzes and reports on medical management metrics to identify trends and recommend interventions
โข Accountable to improving efficiency, cost-effectiveness, and quality in OCA's medical management programs, including through use of new technology as appropriate
โข Contributes to MassHealth's cross-agency medical management strategy
Medical Management Programs
โข Oversees Office of Clinical Affairs Medical Management Programs and functions
โข Oversees and contributes to OCA utilization management initiatives, including related to prior authorization, concurrent review, and retrospective review
โข Oversees and contributes to development and implementation of clinical coverage policies, including assessment of new and existing technologies.
โข Oversees and contributes to clinical reviews of providers
โข Reviews, analyzes, and responds to quality and safety data
โข Ensures high-performing medical management programs that adhere to all relevant regulatory and other requirements, including those set forth by CMS and other oversight entities
Stakeholder Engagement
โข Advises and collaborates with the Chief Medical Officer (CMO) and Medical Directors on
strategic issues involving medical management programs
โข Serves as a lead interface for OCA medical management programs with other teams throughout the agency
โข Leads and/or supports external stakeholder engagements regarding coverage and medical management of services for MassHealth members
Leadership
โข Manages clinical and non-clinical staff who are directly responsible for executing on OCA's medical management initiatives
โข Ensures Medical Management staff maintain up-to-date knowledge, skills and abilities
related to the administration of assigned responsibilities and functions
โข Oversees relevant contractors performing utilization management reviews on behalf of OCA/MassHealth
Other
โข May engage in other clinical policies and program work within the MassHealth portfolio
โข Other duties as assigned
Qualifications
LICENSURE/CERTIFICATION
โข Current, unrestricted physician license in Massachusetts throughout employment with OCA
REQUIRED EDUCATION
โข M.D. or D.O. degree required
โข Board Certified in specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards; Internal Medicine or Family Medicine preferred
REQUIRED QUALIFICATIONS
โข At least 5 years experience in direct patient care post-residency
โข At least 5 years experience in utilization management in a managed care organization/health plan
โข In active clinical practice throughout employment with the Office of Clinical Affairs; internal medicine or family medicine preferred
โข Thorough knowledge of the principles and practices of medical management including utilization management
โข Excellent oral and written communication and presentation skills
โข Must work two days per week on site in Boston and/or Quincy during normal business hours
Additional Information
Preferred Qualifications:
PREFERRED EDUCATION
- Master of Health Administration (MHA), Master of Public Health (MPH), or Master of Business Administration (MBA) in Healthcare Management preferred
PREFERRED QUALIFICATIONS
- Demonstrated commitment to serving Medicaid patients
- Thorough knowledge of Medicaid and related regulations
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