Supervisor, Utilization Management Medicare and Duals (One Care and SCO)

Site: Mass General Brigham Health Plan Holding Company, Inc.

 

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

 

Job Summary

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at 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 welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.

We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.

The supervisor will work closely with the Manager, Clinical, to oversee the daily operations of the DSNP (SCO and OneCare products) utilization management staff. The supervisor will be responsible for the direct coaching, supervision, and evaluation of licensed clinical staff. The supervisor may be required to participate in projects across the organization to support new products or address business needs.

Essential Functions
-Expertise in clinical inpatient and outpatient utilization management reviews utilizing InterQual®, company policies and procedures, and other resources as determined by review, including physician reviews as needed.
-Educate staff on quality review requirements and documentation guidelines, with emphasis on highly accurate and specific documentation consistent with national regulations and practice.
-Monitor individual productivity and adjust assignments as needed to support productivity goals, ensure quality reviews, maintain timeliness, and achieve an equitable distribution of cases.
-Report staff productivity trends and any other department/staff concerns to the manager as needed.
-Ensure site assignments, phone/fax lists, hospital reports, etc., are updated and accurate.
-Monthly review of staff roles, metrics, and quality of work, making readjustments to align with MA regulations and Mass General Brigham Health Plan goals as needed.
-Develop tools and workflows to ensure accuracy and completeness of reviews and documentation.

 

Education

• Bachelor's Degree required; experience can be considered in lieu of a degree

Licenses and Credentials

• Massachusetts Registered Nurse (RN) license required
• Certified Case Manager (CCM) preferred

Experience

• At least 3-5 years of relevant experience in a managed care setting, knowledge of utilization management required
• Experience with inpatient and outpatient levels of review for D-SNP populations
• Understanding of LTSS highly preferred
• Expertise in clinical inpatient and outpatient care required
• Leadership and/or supervisory experience preferred

Knowledge, Skills, and Abilities

• Proficient user with Microsoft Office and McKesson InterQual.
• Excellent verbal, written, listening, and interpersonal skills.
• Demonstrate Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value.

 

Working Conditions

• This is a remote role that can be done from most US states
• There is possible weekend and holiday work, but the role is generally a Monday through Friday daytime schedule

 

Remote

 

399 Revolution Drive