Manager, Medicare and DSNP Utilization Management

Site: Mass General Brigham Incorporated

 

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.

 

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.

 

Job Summary

Responsible for overseeing clinical utilization management (UM) activities to ensure efficient use of resources for Medicare Advantage and DSNP members. Manages a team of clinical professionals, implements best practices, and collaborates with various departments to improve patient outcomes and streamline care processes.

Essential Functions
-Supervise and support a team of care coordinators and case managers, ensuring they adhere to clinical standards and protocols.
-Develop and implement strategies to enhance the efficiency and effectiveness of clinical care coordination.
-Monitor patient care processes and outcomes to ensure compliance with regulatory requirements and hospital policies.
-Facilitate collaboration between clinical teams, physicians, and other healthcare providers to optimize patient care.
-Review and analyze patient data to identify trends, areas for improvement, and opportunities for intervention.
-Conduct regular performance evaluations and provide ongoing training and development for staff members.
-Manage case load assignments and prioritize patient cases based on acuity and resource availability.
-Oversee the implementation of new care models or technologies to improve patient care and operational efficiency.
-Ensure accurate documentation and reporting of case management activities and patient care outcomes.

 

Qualifications

Education

• Bachelor's Degree required
• Master's Degree Related Field of Study

Licenses and Credentials

• Massachusetts Registered Nurse [RN] license required

Experience

• At least 3-5 years of experience in clinical care coordination or case management required
• At least 2-3 years of experience in a supervisory or leadership role required
• At least 2-3 years of Medicare and DSNP UM experience required

Knowledge, Skills, and Abilities

• Strong leadership and team management skills to effectively guide and support clinical staff.
• Excellent communication and interpersonal skills to collaborate with healthcare providers and patients.
• Analytical skills to assess patient care data and identify areas for improvement.
• Problem-solving abilities to address complex care coordination issues and implement effective solutions.
• Knowledge of regulatory requirements and industry best practices in clinical care and case management.
• Proficiency in healthcare management software and electronic health record systems.

 

Additional Job Details (if applicable)

Working Conditions

• While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged.

 

Remote Type

Remote

 

Work Location

399 Revolution Drive

 

Scheduled Weekly Hours

40

 

Employee Type

Regular

 

Work Shift

Day (United States of America)

 

Pay Range

$99,465.60 - $141,804.00/Annual

 

Grade

8

 

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organi