Manager, Utilization Management
Mass General Brigham Health Plan

Job Info

This is a hybrid role with occasional (roughly 1x/every other month) onsite team meetings in Somerville, MA.

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.

The Manager of Utilization Management (UM) leads the daily operations of the UM Department Medicare Advantage 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.

This role will be responsible for developing, implementing, and maintaining policies and procedures related to Medicare. Responsible for performance monitoring and auditing: Monitor and analyze the performance of programs and services for all lines of business, identifying areas for improvement. Provide leadership and guidance to the designated team (based on LOB oversight), fostering a culture of excellence and continuous improvement. Responsible for reporting: Prepare and present regular reports on the performance and status of designated team programs to senior management. The Clinical Manager will also collaborate with other departments, including compliance, finance, and operations, to ensure integrated and efficient service delivery.

Principal Duties and Responsibilities:

• 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, for all lines of business, inclusive of Medicare Advantage
• Presentation of Performance for Volume, Quality and TAT at UM Committee Meetings.
• Work with direct and indirect reports to identify and prioritize objectives that support team and departmental goals
• Participate and engage with process to monitor goals and potential risks of missing target
• Monitor performance of program, departmental and organizational performance metrics including productivity at a department level. Perform root cause analysis on issues that are identified and take actions to avoid similar issues in the future
• Identification of Authorizations that can be reviewed for value, e.g., services that should be recommended for inclusion or removal in PA program.
• Work cross-functionally with other departments, such as Care Management, Customer Service, Appeals, Claims and Quality Improvement, to streamline workflows and enhance the overall member experience.
• Take lead on escalated issues while identifying gaps in process and working with stakeholders to mitigate the risk of future concerns
• Process map all current workflows and ensure workflows remain current
• Identify training and education opportunities and work with Clinical Educator and the Learning and Development team to develop and/or assist with training
• Act as a leader and decision-maker in positioning team's success in audits
• 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 of edit as needed
• Participate in gathering and validating data for all regulatory audits
• 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.
• Hold self and others accountable to meet commitments and build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization
• Use Mass General Brigham healthcare values to govern decisions, actions, and behaviors. These values govern how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Other duties as assigned with or without accommodation.

Qualifications
Qualifications:

• 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
• Certifications: Certification in Case Management (CCM), UM Certification (Interqual) or similar is a plus.
• At least 5-7 years' experience in Utilization Management specific to Medicare Advantage
• At least 3-5 years' experience in leadership roles with progressive responsibilities
• Knowledge: In-depth knowledge of Utilization management 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.

Skills/Abilities/Competencies:

• Proficiency in Word, Excel, PowerPoint.
• Familiarity with Visio and SharePoint
• Analytic ability, computer proficiency, incl. ability to organize information and data.
• Competence in health plan benefit management, regulations/compliance.
• Expertise in staff management, coaching and motivation.
• Strong writing and presentation skills.
• Superior organizational skills.
• Strong collaboration and team building skills.
• Ability to communicate with all levels of individuals in the organization with patience and in a collaborative manner.
• QNXT and SharePoint is a plus.
• Communication excellence: verbal and written proficiency.
• Demonstrate the ability to multi-task and problem solve.
• Ability to successfully manage conflict.
• Customer focused, with strong ethical values.
• Respect the talent and unique contribution of every individual, culture and ethnic group and treat all people in a fair and equitable manner.
• Exercise self-awareness; monitor impact on others; is receptive to and seek out feedback; use self-discipline to adjust to feedback.
• Accountable for delivering high quality work. Act with a clear sense of ownership.
• Proactive in areas of professional development personally and for the department.
• Demonstrate Mass General Brigham Health Plans core brand principles of always listening, challenging conventions, and providing value.
• Bring fresh ideas forward by listening to and working with employees and the people we serve.
• Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner.
• Strong, demonstrated track record of an ability to execute on time, on budget, and on scope.
• Strong aptitude for technology-based solutions.
• Ability to inject energy, when and where it is needed.
• Current in healthcare trends.
• Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be."
• Ability to develop, introduce, defend, and gain support for new ideas and approaches.
• Excellent leadership skills and leadership track record.
• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills. Strong verbal, active listening, and written communication skills required.
• Ability to view the long-range trends and cycles of the business and industry and see the "big picture."
• Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.
• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.
• Excellent interpersonal skills, including the ability to influence others at all levels of an organization.
• Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
• Unquestionable integrity.

Supervisory Responsibilities:

• Provide leadership to Medicare UM staff based online of business.
• Motivates and encourages staff; leads through change and adversity. Makes decisions as needed and builds consensus as appropriate. Communicates and cascades information to employees in a timely manner and actively participates in the success of cross-organizational programs and initiatives.
• Sets clear goals and objectives and uses metrics to measure performance and hold staff accountable. Provides coaching to improve performance and holds regular development discussions with direct reports. Recognizes staff for their contributions.
• Inform, engage, inspire, motivate, and actively listen to employees.
• Make decisions that put the needs of the people we serve-our members, providers, brokers, and employers-front and center.
• Communicate and cascade information to employees in a timely manner and actively participate in the success of cross-organizational programs and initiatives.
• Identify/create processes and align resources to accomplish key objectives; clearly convey and assign clear accountability for important objectives, deadlines, and expectations.
• Hire, participate in, and/or recommend development measures and disciplinary actions up to and including termination; evaluate performance and supervise the work of all direct and indirect reports following established organizational policies, procedures, and practices.
• Set clear goals and objectives, use metrics to measure performance, and hold employees accountable. Provide coaching to improve performance and holds regular development meetings.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.

EEO Statement
Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.