BH Medical Director (Per Diem)

WellSense Health Plan; Northern (KY); Hybrid; USD 176,000 - 238,000; Part time

Benefits offered by this job

Remote work

Competitive compensation

Job summary

WellSense Health Plan is seeking a per diem Medical Director – Behavioral Health to support clinical affairs and utilization management across Massachusetts and New Hampshire. The role involves medical necessity reviews, policy evaluation, and collaboration with physicians and nurses to improve care and reduce costs.

The position requires an MD/DO with extensive managed care experience and board certification in psychiatry (Child & Adolescent).

Qualifications

• MD or DO from an accredited medical school.
• 8-10+ years related experience in a managed care setting.
• Active board certification in psychiatry (Child & Adolescent) and licensed to practice in MA/NH or able to obtain.
• Pre-employment background check and unrestricted licensure.

Responsibilities

• Provide clinical case review and oversight for utilization management.
• Review prior authorizations, concurrent reviews, and retrospective medical necessity reviews.
• Apply InterQual criteria and Medical Policy consistently.
• Collaborate with hospital physicians and nurse case managers to improve population health and reduce costs.
• Chairs or participates in clinical committees as assigned.

Skills

Clinical decision making

Utilization management

InterQual familiarity

Healthcare policy

Leadership

Education

MD/DO

Tools

NCQA knowledge

InterQual protocols

Job description

WellSense Health Plan is a nonprofit health insurance company serving more than 680,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded more than 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

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

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.

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