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Senior Manager of Clinical UM BH
2 months ago
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.
Job Summary:
The Senior Manager of Clinical Utilization Management (UM), Behavioral Health is responsible for the overall coordination and management of health plan UM processes, operations, and outcomes for all product lines. Analysis of available data to measure individual and team performance, clinical program performance, team processes and compliance are essential. Working with his or her staff, the Senior Manager will anticipate and resolve complex issues to ensure timely and cost effective outcomes and the achievement of productivity and quality metrics.
Additionally, the Senior Manager will work in conjunction with the Senior Director of Behavioral Health (BH) Clinical Programs on a variety of critical assignments including the management of one or more focused clinical initiatives and representing the company externally in presentations with key provider and member groups. The Senior Manager will develop and implement policies and procedures that integrate state and federal regulations to ensure compliance with government agency requirements.
Our Investment in You:
· Full-time remote work
· Competitive salaries
· Excellent benefits
Key Functions/Responsibilities:
__
Process
At the direction of the Senior Director of BH Clinical Programs, independently leads new BH UM program development and implementation, starting with the build-out of the BH UM program and team in support of an insourced model.
Manages the clinical activities of UM programs including the development and implementation of effective metrics to monitor productivity, composition of program descriptions and development of
workflows and job aids and management of clinical staff as well as facilitation of team meetings.
Identifies areas for improvement of existing department policies and procedures and works with department senior management for implementation; follows through with evaluation.
Oversees the analysis, development, implementation and evaluation of the UM clinical programs and policies so that quality, documentation, policies and procedures are consistent with current federal and state regulations and applicable accreditation standards (e.g., NCQA)
Responsible for achievement of medical cost management and NCQA accreditation team initiatives and working with the appropriate departments to improve their understanding of how these standards impact their departments.
Liaison to Legal, Compliance and Quality Department on issues that have both legal risk and compliance aspects.
Partners with the Accreditation Manager on NCQA audits and is responsible for all corrective actions in assigned area.
Works closely with all appropriate internal departments on issues related to UM and readmissions, including partnering on clinical presentations for provider and member groups.
Works with Clinical and Quality Management leadership team to develop division goals, strategies and resource needs.
Assists the Senior Director of BH Clinical Programs in development of and managing the (clinical) department budget.
Works closely with the Medical Policy Manager and Medical Directors regarding issues arising from UM reviews so that criteria in need of change are dynamically tracked.
Attends policy, technology, and quality improvement meetings, as well as other key department/organization meetings.
Leads and oversees coordination and integration between UM and other clinical departments (e.g. Care Management, Pharmacy, and delegated Vendors), including Clinical Rounding programs.
Acts as key resource to Medical Directors in the performance of UM activities.
Notifies the Senior Director of BH Clinical Programs if department or staff performance falls below expectations, and works with leadership to develop a plan to improve performance.
People
Develops a high-performance team as evidenced by:o Meeting all process requirements
* Eliciting the team’s participation in identifying opportunities for improvement Meeting defined team goals such as targeted results of an annual team survey Developing performance management skills in supervisory staff by modeling, managing, and setting clear expectationsDevelops and oversees the execution of Clinical UM staff onboarding and ongoing role specific training
· Oversees the development and execution of individual professional development plans for all direct reports consistent with the corporate performance management program
Data/Technology
Oversees the consistent use of support technologies Partners with BH leaders and others to identify reporting needs and develop the reports. Works with other business areas including IT, Clinical Informatics, and Quality as related to business requirement development, clinical management software configuration for existing and new system implementations, and UAT__
Supervision Exercised:
· Direct supervision of eight (8) or more FTEs and indirect supervision of 1-5 FTEs if required
Supervision Received:
· General supervision is received weekly
Qualifications:
__
Education Required: __
· Master’s Degree in a behavioral health field such as Social Work or Psychology along with relevant work experience is required.
Education Preferred:
· Academic certificates or other demonstrations of relevant professional development and continuing education.
Experience Required: __
· Minimum five years of experience managing BH staff in a healthcare organization required
· Minimum five years of experience with prior authorization, utilization review, and discharge planning
· Minimum of three years of experience working in an acute care or health insurance environment is required
Experience Preferred/Desirable:
· Experience in acute care and/or residential settings
· Experience with Medicaid recipients and community services
· Experience with FACETS, Jiva, InterQual or other healthcare system
· Experience in a health plan or insurance environment
Required Licensure, Certification or Conditions of Employment:
· Pre-employment background check
· Current certificate or state licensure in Massachusetts and New Hampshire as LICSW, LMHC, or Licensed Psychologist, in good standing
Competencies, Skills, and Attributes:
· Ability to recruit, develop, and lead an effective, high-functioning team
· Ability to successfully plan, organize and manage projects within a health care setting
· Experience with data-driven decision making
· Strong organization and time management skills
· Ability to work in a fast paced environment; ability to multi-task
· Experience with standard Microsoft Office applications, particularly MS Outlook, MS Word, Excel, and other administrative applications
· Strong oral and written communication skills including presentation skills and ability to interact with all levels of the organization
· Strong analytical and clinical problem solving skills
Working Conditions and Physical Effort:
Travel within Massachusetts and New Hampshire for team meetings, provider meetings, community events and other meetings and events. Regular and reliable attendance is an essential function of the position. Work is normally performed in a typical interior/office work environment or remotely. Heavy computer use for administrative work and video calls/meetings. No or very limited physical effort required. No or very limited exposure to physical risk.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
Required Skills
Required Experience
