Clinical Manager, Utilization Management

2 weeks ago


Somerville, Massachusetts, United States Mass General Brigham Health Plan Full time
Job Summary

We are seeking a highly skilled Clinical Manager, Utilization Management to join our team at Mass General Brigham Health Plan. As a key member of our Utilization Management department, you will be responsible for overseeing the operational management of Medicare utilization management operations, ensuring compliance with regulatory requirements, and driving business growth through process improvements.

Key Responsibilities
  • Oversee utilization management operations for Medicare Advantage, achieving best-in-class performance
  • Prioritize, vet, and implement a focused set of key performance indicators across the Medicare UM team, including member service, quality indicators, cost savings, and regulatory requirements
  • Establish targets, based on industry benchmarks, which support company goals and regulatory requirements
  • Manage standard processes to evaluate operational performance and make decisions to adjust resource allocations, processes, and targets in consultation with stakeholders
  • Establish quality assurance measures to monitor the accuracy and effectiveness of Medicare UM resolutions
  • Implement mechanisms for tracking and analyzing data related to Medicare UM outcomes, identifying trends and areas for improvement
  • Prepare and present regular reports on the performance and status of Medicare programs to senior management
  • Identify process improvement opportunities and convene stakeholders to discuss current state and future interventions
  • Ensure that Medicare UM meets compliance requirements for CMS
  • Stay abreast of Medicare Advantage regulations and guidelines related to Utilization Management
  • Ensure that all processes and procedures are compliant with regulatory standards, conducting regular audits and assessments to mitigate risks and address any areas of non-compliance
  • Act as a leader and decision-maker in positioning team's success in audits
  • Analyze data and engage other departments as required to review trends and develop solutions
  • Develop evaluation tools to measure and track the success of any implemented solutions
  • Lead report validation in line with compliance requirements
  • Review, validate, and maintain data dashboards and work with IT to enhance or edit as needed
  • Ensure consistent approach to documentation specific to regulatory requirements
  • Perform trend analysis to identify risk and opportunities
  • Take lead on external report requests, identifying changes year over year and analyzing for any opportunities with plan performance
  • Participate in gathering and validating data for all regulatory audits
Requirements
  • Bachelor's degree in Nursing (BSN) required; Master's degree in Nursing, Healthcare Administration, or related field preferred
  • Licensure: Current and valid Registered Nurse (RN) license. Will need to obtain MA Licensure
  • Certifications: Certification in Case Management (CCM) or similar is a plus
  • At least 5-7 years' experience in Medicare Utilization Management
  • At least 3-5 years' experience in leadership roles with progressive responsibilities
  • Knowledge: In-depth knowledge of Medicare regulations, managed care principles, and healthcare delivery systems
  • Skills: Strong leadership, analytical, and communication skills. Proficiency in healthcare management software and Microsoft Office Suite
  • Leadership: Strong organizational and management experience required, preferably in a healthcare setting
About Us

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. 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.


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