Medical Director. Clinical Management

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

The Medical Director, Clinical Management serves as a physician leader responsible for supporting the clinical, operational, and strategic activities of Fallon Health's Clinical Management programs. The Medical Director provides leadership and direction to the Associate Medical Directors and collaborates closely with the VP and Senior Medical Director of Clinical Management to ensure the delivery of high-quality, cost-effective, evidence-based care management and utilization management programs.

This position is responsible for conducting medical necessity reviews, provider and member appeals, peer-to-peer consultations, and medical director on-call activities. The Medical Director serves as a clinical resource to care management, utilization management, pharmacy, quality, network management, compliance, operations, and other departments. The individual partners with senior leadership to identify opportunities for program improvement, regulatory compliance, quality enhancement, operational efficiency, and medical expense management.

The Medical Director represents Clinical Management on organizational initiatives, committees, and cross-functional workgroups and may chair designated committees related to utilization management, care management, appeals, medical policy, quality, or clinical operations.

• →Conduct initial and secondary medical necessity reviews for inpatient, outpatient, home health, skilled nursing facility, pharmacy, and other health care services.
• →Review and render determinations for provider and member appeals in accordance with regulatory and accreditation requirements.
• →Conduct peer-to-peer consultations with treating providers.
• →Responsible for the Associate Medical Director daily and on call schedules
• →Participate in medical director on-call rotation.
• →Provide clinical support and consultation to utilization management nurses, case managers, pharmacists, and other clinical staff.
• →Participate in inpatient, outpatient, and complex case management rounds as directed.
• →Support benefit interpretation and application of evidence-based medical necessity criteria.

• →Provide direct oversight, mentoring, coaching, and performance management for Associate Medical Directors.
• →Promote consistency and clinical integrity in medical necessity determinations, appeal decisions, and utilization management activities.
• →Assist in developing physician reviewer standards, quality assurance activities, and inter-rater reliability processes.
• →Support recruitment, onboarding, and professional development of physician reviewers.
• →Serve as a clinical resource for internal departments and external stakeholders.

• →Partner with the VP and Senior Medical Director of Clinical Management in the development and implementation of clinical management strategies and initiatives.
• →Assist in identifying emerging trends in utilization, quality, member outcomes, and medical expense.
• →Support development of programs addressing high-cost, high-risk, and emerging areas of utilization.
• →Collaborate in the design and implementation of initiatives intended to improve affordability, quality, member experience, and operational effectiveness.
• →Participate in development and refinement of utilization management, care management, and appeals processes.
• →Assist in evaluating program performance, productivity, regulatory compliance, and operational outcomes.

• →Support special projects and initiatives as assigned by the VP and Senior Medical Director of Clinical Management.
• →Maintain current knowledge of regulatory requirements, clinical guidelines, and industry best practices.
• →Perform other duties as assigned.

• Serve as a clinical subject matter expert for Long-Term Services and Supports (LTSS), including Personal Care Attendant (PCA) services, supporting Utilization Management and Care Management initiatives.
• Collaborate with LTSS program leadership, Care Management, Utilization Management, Quality, Compliance, and Provider Relations teams to address complex clinical, operational, and regulatory issues.
• Provide clinical consultation and recommendations regarding LTSS program design, PCA services, member care needs, and emerging best practices.
• Participate in the development and evaluation of LTSS-related policies, workflows, and program improvement initiatives to enhance member outcomes and ensure regulatory compliance.
• Represent Clinical Management on enterprise initiatives and cross-functional teams.
• Collaborate with Network Management and Contracting on clinical aspects of provider network development and value-based initiatives.
• Partner with Quality, Compliance, Operations, Medical Expense Management, Population Health, Pharmacy, and Care Management teams on clinical and operational priorities.
• Provide clinical support to Medical Policy, Payment Policy, and related governance committees.
• Participate in regulatory reviews, accreditation activities, audits, and corrective action initiatives as needed.

• Chair and/or participate in utilization management, appeals, medical policy, quality, and other clinical governance committees as assigned.
• Present clinical management program outcomes, trends, and recommendations to organizational leadership and committees.
• Support implementation and monitoring of committee decisions and action plans.

• M.D. or D.O. degree from an accredited medical school or school of osteopathic medicine
• Board certification in an ABMS-recognized specialty
• Additional training in utilization management, appeals, care management, quality improvement, population health, or managed care preferred
• Strong understanding of Medicare, Medicaid, and Commercial health plan operations
• Knowledge of evidence-based medicine, clinical guidelines, and medical necessity review processes

MD

• Minimum of three years of direct patient care experience
• Significant experience in managed care, utilization management, prior authorization, appeals, care management, or medical policy
• Experience conducting medical necessity reviews, level of care determinations, and provider/member appeals
• Experience leading physician and interdisciplinary teams
• Demonstrated ability to collaborate across operational, clinical, and administrative departments
• Experience with CMS, NCQA, Medicaid, and other regulatory and accreditation requirements preferred
• Experience analyzing utilization trends, quality outcomes, and medical expense drivers preferred