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The Medical Director supports the Non-Institutional Provider Review (NIPR) Program. The Non-Institutional Provider Review Unit (NIPR) oversees retrospective, post-payment case reviews of community-based providers who participate in MassHealth. In collaboration with MassHealth, the purpose of these reviews is to detect possible fraud, waste, and abuse and to ensure compliance with the regulations governing MassHealth as well as to determine whether the services were medically necessary, appropriate, and of a quality that meets professionally recognized standards.

Under the direction of the Sr. Medical Director of the Office of Clinical Affairs (OCA) or his/her designee, this position is responsible for providing clinical expertise to NIPR, the OCA, and EOHHS. Serves as a pivotal role supporting NIPR and will work closely with the manager of NIPR and external peer-reviewers throughout the review process including, but not limited to, ensuring each case review is conducted in accordance with professional clinical standards, MassHealth protocols and all other applicable regulations, as well as representing NIPR and MassHealth at Board of Hearing appeals.

Oversee the NIPR Peer Review process to ensure reviews are performed consistently between reviewers, violations are being appropriately assigned, and MassHealth regulations are being adhered to.
Perform an initial high-level review of all cases in collaboration with NIPR nurses.
Prepare all cases requiring a peer review, with help from NIPR nurse reviewers and external peer-reviewers.
Actively participate in all aspects of the peer review process especially in collaborating with external peer-reviewers.
Conduct thorough and timely Peer Reviews, according to NIPR process.
Conduct inter-rater reliability and quality assurance of the peer reviewers work product, ensuing applicable violations are cited and verifying that peer reviews are accurate, consistent and supported by evidence from the medical record and applicable professional standards.
Prepare a comprehensive summary of the case review findings.
Represent NIPR and MassHealth at Board of Hearings
Defend case review findings at an adjudicatory hearing with the Board of Hearings.
Provide clinical leadership, support, and subject matter expertise to the activities of the NIPR Unit.
Conduct peer-to-peer discussions, as applicable, and educate physicians and others on the NIPR process.
Work collaboratively with both clinical and non-clinical team members.
Build and maintain effective working relationships with cross-functional leaders and teams in order to identify, explore, present and implement clinical opportunities.
Propose and implement necessary process improvement to improve efficiency and impact in collaboration with Sr. Medical Director and Manager of NIPR
Perform other similar and related duties as required or as directed.

REQUIRED EDUCATION

Licensed Medical Doctor or Doctor of Osteopathy

REQUIRED QUALIFICATIONS
Licensed Medical Doctor or Doctor of Osteopathy
Actively licensed to practice medicine without restriction in Massachusetts throughout his/her employment with OCA
Board certified in an area of specialty with at least 5 years of clinical experience
A minimum of three (3) years of experience in Peer Review
Excellent oral and written communication skills
Experience in the application of state and federal Medicaid rules and regulations.
Must work onsite during normal business hours* (this position is currently Hybrid)

PREFERRED QUALIFICATIONS
Actively practicing physician in their area of specialty.

REQUIRED WORK EXPERIENCE
Experience in Peer Review and utilization review work.
Experience in conducting inter-rater reliability and quality assurance.

PREFERRED WORK EXPERIENCE
Experience in defending case reviews at appeal level.
Experience in detecting fraud, waste, and abuse.
A graduate degree in Public Health or Public Policy, or other advanced degrees in business or healthcare, or equivalent degree, is highly desirable.

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