Manager, Medicare and DSNP Utilization Management

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 worlds 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.

Responsible for overseeing clinical utilization management (UM) activities to ensure efficient use of resources for Medicare Advantage and D-SNP members including populations receiving Long-Term Services and Supports (LTSS). 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.

Education

• Bachelors Degree required
• Masters 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
• LTSS (Long-Term Services and Supports) experience preferred
• 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.

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

399 Revolution Drive

40

Regular

Day (United States of America)

Pay Range

$99465.60 - $141804.00/Annual

Grade

8

At Mass General Brigham we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive and any offer extended will take into account your skills relevant experience if applicable education certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however it does not encompass all elements contributing to your total compensation addition to competitive base pay we offer comprehensive benefits career advancement opportunities differentials premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

8925 Mass General Brigham Health Plan Holding Company Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973 the Vietnam Veterans Readjustment Act of 1974 and Title I of the Americans with Disabilities Act of 1990 applicants who require accommodation in the job application process may contact Human Resources at .

Mass General Brigham Competency Framework