Utilization Management Care Manager, RN
Utilization Management Care Manager, RN
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Salary Not Disclosed
1 Vacancy
Job Description
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
The Utilization Management Care Manager (UMCM) will utilize clinical knowledge to analyze assess and render approval decisions to determine the need for physician review as well as complete determinations following physician review. The ideal candidate will have worked at another health plan doing prior authorizations for procedures like IVF surgeries and high-tech radiology.Essential Functions
Review 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 the MGB Health Plan as needed.
Manage incoming requests for procedures and services including patient medical records and related clinical information.
Adherence to program departmental and organizational performance metrics including productivity.
Excellent communication skills both verbal and written; excellent problem-solving and customer service skills are required.
Would need to be available for on call for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire.
Must be self-directed and highly motivated with an ability to multi-task.
Develop and maintain effective working relationships with internal and external customers
Hold self and others accountable to meet commitments.
Ensure diversity equity and inclusion are integrated as a guiding principle.
Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
Build strong relationships and infrastructures that designate MGB Health Plan as a people-first organization.
Qualifications
Education
- Associates Degree Nursing required or Bachelors Degree Nursing preferred
Licenses and Credentials
- MA Registered Nurse (RN) with a current state license required
Experience
- At least 3-5 years of utilization management experience is highly preferred
- UM certification (InterQual) preferred
- At least 1-2 years of experience in a payer setting highly preferred
- Experience using InterQual/Milliman preferred
Knowledge Skills and Abilities
- Giving full attention to what other people are saying taking time to understand the points being made asking questions as appropriate and not interrupting at inappropriate times.
- Using logic and reasoning to identify the strengths and weaknesses of alternative solutions conclusions or approaches to problems.
- Ability to establish strong rapport and relationships with patients and staff.
- Proficient in Microsoft Office and industry related software programs.
- Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
- Ability to maintain client and staff confidentiality.
- Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
- Knowledge of Healthcare and Managed Care preferred.
Additional Job Details (if applicable)
Working Conditions
- This is a remote role that can be done from most US states. It will require occasional time at the office (roughly 1x/quarter) for team meetings in Somerville MA
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
Required Experience:
Manager
Employment Type
Full-Time
