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    5 months ago

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    3 weeks ago

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Manager, Utilization Management

2 months ago

Somerville, United States Mass General Brigham Full time

DescriptionMass General Brigham Health Plan is an exciting place to be within the healthcare industry. Please make sure you read the following details carefully before making any applications. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated. We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.The Manager of Utilization Management (UM) leads the daily operations of the UM Department (Government Programs (Medicare Advantage and Medicaid) as well as Commercial (inclusive of ASO)), including maintaining appropriate Quality, Turn Around Time and Volume of prior authorizations for all services requiring a prior auth (PA), along with Regulations, Reporting and Appeals.The Manager of UM is also responsible for deploying technology and resources to support the functions, developing and maintaining Policies regarding process, along with managing delegated providers performing services under agreement.The Manager of UM is also responsible for managing staff (development / succession planning) and delivering internal and external communication at a high standard, including collaborative oversight with Manager of Care Management of the Clinical Navigator function.Principle Duties:· Lead the oversight of department performance for reviewing authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within Mass General Brigham Health Plan as needed.· Development & maintenance of Policies related to the services delivered by the Utilization Management Department, inclusive of those for Governmental Programs (Medicare Advantage and Medicaid) as well as Commercial (inclusive of ASO)).· Presentation of Performance for Volume, Quality and TAT at UM Committee Meetings. · Monitor performance of program, departmental and organizational performance metrics including productivity at a department level.· Identification of Authorizations that can be reviewed for value, e.g., services that should be recommended for inclusion or removal in PA program.· Collaborative development and ongoing oversight of Clinical Navigator function with Manager of Care Management in partnership with Sales.· Excellent communication skills both verbal and written; excellent problem solving, and customer service skills are required.· Maintain UM Standards and regulatory compliance (inclusive of Department of Insurance (DOI), Executive Office of Health and Human Services (EOHHS), Centers for Medicare & Medicaid Services CMS) working collaboratively with compliance officer(s) for the respective program, including NCQA guidelines.· Work with Denials/Appeals group regarding any escalated matters. · Hold self and others accountable to meet commitments.· Ensure diversity, equity, and inclusion are integrated as a guiding principle.· Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.· Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.· Other duties as assigned with or without accommodation.QualificationsBasic Requirements:· Bachelor’s degree required in Healthcare of Business or the equivalent combination of training and experience, plus 7-10 years of related clinical experience and 3-5 managed care experience· Minimum of 5 years management experience.· Registered nurse (RN) with current MA license, plus BSN or equivalent experience.· UM Certification (InterQual).Job Field: Professional/ManagerialOrganization: Mass General Brigham Health PlanSchedule: Full-timeShift: Day JobEmployee Status: Regular Remote working/work at home options are available for this role.