Site: Mass General Brigham Health Plan Holding Company, Inc.
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?
Yes
QualificationsEssential 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 required
Can this role accept experience in lieu of a degree?
No
Licenses and CredentialsPhysician [State License] - Generic - HR Only required
Experience:Clinical Experience 8-10+ years required and Experience in managed care, health plan, or population health leadership role 5-7 years required
Knowledge, Skills and Abilities:- Strategic thinking and clinical judgment
- Executive communication and influence
- Data-driven decision-making
- Collaborative leadership
- Regulatory and compliance awareness
- Provider engagement and relationship-building
Salary Range:
$320 - $350K (depending upon experience)
Additional Job Details (if applicable)Remote TypeRemote
Work Location399 Revolution Drive
Scheduled Weekly Hours40
Employee TypeRegular
Work ShiftDay (United States of America)
