Medical Director

Job Summary

The Medical Director will report to the Senior Medical Director of Utilization Management, Member Appeals & Grievances, and Medical Policy (Senior Medical Director of Utilization Management) and support the staff of the Office of Clinical Affairs in the areas of medical management daily medical necessity reviews, evaluation of medical policy, utilization trend management, quality, appeals and grievances, and pharmacy reviews.

Key Functions/Responsibilities

• Provides clinical case review, consultation and oversight for all utilization management activities in a fashion that is compliant with all federal, state, and NCQA requirements
• Conducts review of prior authorizations, concurrent reviews and retrospective medical necessity reviews that do not meet standard criteria and determines coverage
• Works with the Senior Medical Director of Utilization Management to identify appropriate use of InterQual criteria and Medical Policy
• Works with the Senior Medical Director to ensure consistent medical decision making for all physician reviewers, including the contracted physicians
• Conducts clinical review of appeals and grievances in a fashion that is compliant with all federal, state and NCQA requirements
• Develops and supports clinical initiatives to support department quality improvement and utilization management goals
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
• Collaborates with hospital physicians, medical directors, primary care physicians and nurse case managers in daily activities and initiatives to improve the health of the population, the quality and experience of care our members receive, and lower the overall cost of care at the population level
• Participates in and chairs clinical committees as assigned by the Senior Medical Director of Utilization Management
• Supports quality, and pharmacy committees and activities
• Provides input to the strategic planning process for the Office of Clinical Affairs as requested
• Represents the Chief Medical Officer or Senior Medical Directors in Massachusetts, New Hampshire and other locations as requested

Qualifications

• Education: Graduate as a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) from an accredited allopathic or osteopathic medical school
• Experience: 8-10+ years of related experience is required including a minimum of 5 years direct clinical experience and a minimum of 3 years experience in medical management in a managed care setting
• Preferred/Desirable: Preference for those with Board Certification in the following: Internal Medicine, Internal Medicine-Pediatrics (Med Peds), Family Medicine, Emergency Medicine

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Compensation Range

$173,000 - $250,000

Working Conditions and Physical Effort

• Work is normally performed in a typical remote interior/office work environment
• No or very limited physical effort required. No or very limited exposure to physical risk
• Able to travel to locations within New Hampshire and Massachusetts
• Regular and reliable attendance is an essential function of the position

Note

This range is based on Boston-area data, and is subject to modification based on geographic location.