Senior Medical Director, Medical Management

Senior Medical Director for Medical Management

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
Leads development and implementation of Office of Clinical Affairs strategy for medical management to ensure appropriate, efficient, and high quality care delivery
Collects, analyzes and reports on medical management metrics to identify trends and recommend interventions
Accountable to improving efficiency, cost-effectiveness, and quality in OCA's medical management programs, including through use of new technology as appropriate
Contributes to MassHealth's cross-agency medical management strategy

Medical Management Programs
Oversees Office of Clinical Affairs Medical Management Programs and functions
Oversees and contributes to OCA utilization management initiatives, including related to prior authorization, concurrent review, and retrospective review
Oversees and contributes to development and implementation of clinical coverage policies, including assessment of new and existing technologies.
Oversees and contributes to clinical reviews of providers
Reviews, analyzes, and responds to quality and safety data
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
Advises and collaborates with the Chief Medical Officer (CMO) and Medical Directors on strategic issues involving medical management programs
Serves as a lead interface for OCA medical management programs with other teams throughout the agency
Leads and/or supports external stakeholder engagements regarding coverage and medical management of services for MassHealth members

Leadership
Manages clinical and non-clinical staff who are directly responsible for executing on OCA's medical management initiatives
Ensures Medical Management staff maintain up-to-date knowledge, skills and abilities related to the administration of assigned responsibilities and functions
Oversees relevant contractors performing utilization management reviews on behalf of OCA/MassHealth

Other
May engage in other clinical policies and program work within the MassHealth portfolio
Other duties as assigned

Qualifications

Licensure/Certification
Current, unrestricted physician license in Massachusetts throughout employment with OCA

Required Education
M.D. or D.O. degree required
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

At least 5 years experience in direct patient care post-residency
At least 5 years experience in utilization management in a managed care organization/health plan
In active clinical practice throughout employment with the Office of Clinical Affairs; internal medicine or family medicine preferred
Thorough knowledge of the principles and practices of medical management including utilization management
Excellent oral and written communication and presentation skills
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

UMass Chan Medical School