Senior Medical Director, Health Plan

Site: Mass General Brigham Health Plan Holding Company, Inc.Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.Job SummaryThe Senior Medical Director serves as a key clinical executive within the health plan, providing strategic leadership, medical oversight, and clinical expertise to ensure high‑quality, cost‑effective care for members. This role partners closely with executive leadership, clinical operations, network management, quality, and compliance teams to shape clinical strategy, guide utilization management, and support value‑based care initiatives. The Senior Medical Director represents the health plan externally with providers, regulators, and community partners.Does this position require Patient Care?YesQualificationsEssential Function:Develop and execute clinical strategies that improve member outcomes, reduce unnecessary utilization, and support organizational goals and provide medical expertise to guide benefit design, population health programs, and value‑based care models.Serve as a clinical advisor to senior executives and cross‑functional teams.Oversee utilization management (UM) programs, ensuring evidence‑based, timely, and compliant decision‑making.Review complex or escalated cases, appeals, and grievances, and ensure UM policies align with regulatory requirements, accreditation standards, and clinical best practices.Lead quality improvement initiatives, including HEDIS, Stars, NCQA, and other performance programs, and partner with analytics teams to identify trends in utilization, quality, and member health outcomes.Support the development of population health programs targeting chronic disease management, behavioral health, and social determinants of health.Collaborate with provider network teams to improve clinical performance, reduce variation, and support value‑based contracting, and engage with physicians and health systems to promote evidence‑based care and address performance issues.Represent the health plan in provider forums, committees, and external meetings.Ensure clinical programs comply with federal and state regulations, accreditation standards, and internal policies, and participate in audits, regulatory reviews, and accreditation activities.Maintain up‑to‑date knowledge of evolving healthcare regulations and clinical guidelines.Partner with behavioral health, pharmacy, care management, and social care teams to coordinate integrated care strategies.Provide medical leadership for product development, member engagement initiatives, and clinical innovation projects, and support executive leadership with clinical insights for strategic planning and organizational decision‑making.Education:Doctorate Related Field of Study requiredCan this role accept experience in lieu of a degree?NoLicenses and CredentialsPhysician License. Must hold or be able to obtain a full active Massachusetts physician license. Must have 3-5 years of Health Plan experienceMust have prior experience in utilization management, peer to peer discussionsExperience:Clinical Experience 8-10+ years required and Experience in managed care, health plan, or population health leadership role 5-7 years requiredKnowledge, Skills and Abilities:Strategic thinking and clinical judgmentExecutive communication and influenceData‑driven decision‑makingCollaborative leadershipRegulatory and compliance awarenessProvider engagement and relationship‑buildingSalary Range:$320 - $350K (depending upon experience)Additional Job Details (if applicable)Remote TypeRemoteWork Location399 Revolution DriveScheduled Weekly Hours40Employee TypeRegularWork ShiftDay (United States of America)EEO Statement:8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at View phone number on click.appcast.io.Mass General Brigham Competency FrameworkAt Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.SummaryLocation: Somerville-MAType: Full time