Site: Mass General Brigham Health Plan Holding Company, Inc.
Job Summary
The Senior Medical Director serves as a key clinical executive within the health plan, providing strategic leadership, medical oversight, and clinical expertise to ensure highquality, costeffective 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 valuebased care initiatives. The Senior Medical Director represents the health plan externally with providers, regulators, and community partners.
Does this position require Patient Care?
Yes
Essential 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 valuebased care models.
- Serve as a clinical advisor to senior executives and crossfunctional teams.
- Oversee utilization management (UM) programs, ensuring evidencebased, timely, and compliant decisionmaking.
- 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 valuebased contracting, and engage with physicians and health systems to promote evidencebased 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 uptodate 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 decisionmaking.
Education:
Doctorate Related Field of Study required
Can this role accept experience in lieu of a degree?
No
Licenses and Credentials
Physician License. Must hold or be able to obtain a full active Massachusetts physician license.
Must have 3-5 years of Health Plan experience
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
- Datadriven decisionmaking
- Collaborative leadership
- Regulatory and compliance awareness
- Provider engagement and relationshipbuilding
Salary Range:
$320 - $350K (depending upon experience)
Additional Job Details (if applicable)
Remote
399 Revolution Drive
40
Regular
Day (United States of America)
