Inpatient Utilization Management Team Manager

2 months ago

Canton, Massachusetts, United States Point32Health Full time
Job Summary

The Inpatient Utilization Management Team Manager is responsible for overseeing the day-to-day operations of the Inpatient Utilization Management (UM) process. This includes managing Utilization Management Clinicians, implementing and monitoring department functions and programs, and delivering defined metrics to validate business unit/program effectiveness.

Key Responsibilities
  • Business Process Implementation and Oversight
    • Accountable for developing, implementing, and evaluating new and existing medical management programs for inpatient utilization and discharge planning, including:
    • Commercial or Public Plan telephonic and onsite utilization management across the inpatient level of care, including management of complex utilization cases in acute inpatient, LTAC, skilled nursing, and rehabilitation facilities
    • Development and implementation of operational measures and reporting for functions within the business unit in collaboration with clinical services informatics
    • Collaborative interface with case management program leaders, supporting transition of care needs, complex discharge planning, and high-risk members
    • Collaboration with department and training resources to ensure development and maintenance of an evidence-based training program
    • Establishment of written policies and procedures pertaining to Commercial or Public Plan Utilization Management and Transition of Care/discharge planning program processes, documentation standards, and activities
    • Establish written policies and procedures pertaining to Commercial or Public Plans Inpatient Management to assure compliance with applicable state, federal, and regulatory and accrediting agencies
    • Ensure compliance with applicable contractual service agreements with network, vendor, and employer business partners
    • Oversees the identification of high-risk/high-cost complex members for appropriate program case management through proactive concurrent review process
    • Manages the function of analyzing metric-driven data to determine the impact of plan policies and benefits upon the Plan, Providers, membership, and groups
    • May assist Director with staffing ratios and budget requirements for the department as needed
    • Develop, review, revise, and monitor workflows and procedures to ensure that all work of the medical inpatient management team meets all compliance, regulatory, and accrediting standards for NCQA, DOI, and EOHHS while integrating product-specific management programs
    • Serves as a consultant and resource to Team Manager and staff for complex situations that arise around regulatory issues
  • Staff Development
    • Provides direct oversight of Team Managers within the jurisdiction
    • Guides and enhances the professional development of the team manager and staff, providing coaching, feedback, and direction through a development plan to ensure successful achievement of business and professional goals
    • Assists Team Manager with coaching and mentoring skills as needed
    • Guides and enhances the professional development of reporting staff
    • Collaborates on development and ensures maintenance of an evidence-based training program
    • Serves as a consultant and resource for complex situations
  • Resource Management
    • Supports the budget process and oversees the management of department resources
    • Accountable for realizing department administrative budget targets
  • Corporate Participation
    • Represents Clinical Services/Inpatient Management in relevant corporate teams as required
    • Implements and supports fulfillment of corporate goals through defined, measurable department goals
    • Enhances employee engagement through defined initiatives and resources
    • Participates in corporate initiatives and projects within the jurisdiction
    • Other projects and duties as assigned

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