It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

We’re looking for multiple people who can commit to be available 1-2 days a week, for the full business day

Job Summary

The Medical Director -BH per diem will support the staff of the Office of Clinical Affairs and Behavioral Health teams in the areas of medical management daily medical necessity reviews, evaluation of medical policy, utilization trend management, quality, appeals and grievances, and pharmacy reviews.

Our Investment in You

Per Diem work
Competitive salaries
Excellent benefits

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 Behavioral Health 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 Behavioral Health
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.

Supervision Exercised

Indirect technical direction is provided to the organization.

Supervision Received

General direction is received weekly.

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
3 years experience in medical management in a managed care setting is ideal.

Preferred/Desirable

Certification or Conditions of Employment

Pre-employment background check
Active or lifetime board certification in psychiatry (Child and Adolescent specialty) from the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry
Current unrestricted licensure as an MD in the Massachusetts and New Hampshire is required, or able to obtain in a reasonable timeframe.
No restriction on participation in Medicare or Medicaid programs

Competencies, Skills, and Attributes

Excellent demonstrated clinical skills and knowledge
Excellent written and verbal communication skills.
Comprehensive knowledge of accrediting organizations such as NCQA.
Comprehensive knowledge of InterQual protocols, HEDIS, and other quality measures.
Knowledge of Medicare and state Medicaid regulations, guidelines, and standards.
Proven leadership skills and relationship building
Knowledge of managed care principles and processes.
Ability to work independently with intermittent supervision.
Adhere to appropriate turn-around-times and deadlines while maintain results of high quality and reliability.

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.
Ability to travel to locations within New Hampshire and Massachusetts
Regular and reliable attendance is an essential function of the position.

Compensation Range

$150.00/ Hour

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

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

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.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

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