Utilization Managment Care Manager

This is a remote role with occasional (roughly 1x/every other month) onsite team meetings in Somerville, MA. This role also has a one month minimum "on call" component with the possibility of that increasing depending on staff availability.

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 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 for outpatient commercial reviews.

Essential Functions

• Apply expertise in clinical reviews of prospective, concurrent, retrospective utilization management reviews utilizing InterQual ®, company policies and procedures, and other resources as determined by review, including physician reviews as needed.

• 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 Mass General Brigham 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 and weekends; 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.

• Sound decision making and time management skills.

• Proactive in areas of professional development personally and for the department.

• Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual ®, Outlook, SharePoint, PC based operating system, and web-based phone system

• 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 Mass General Brigham Health Plan as a people-first organization.

• Other duties as assigned with or without accommodation.

Working Conditions

• Will need to be available for "on call" for a minimum of once per month with the possibility of that increasing depending on staff availability and weekends; Approximately 6 months after hire.

• Work is normally performed in a typical remote work environment with occasional (roughly 1x/every other month) onsite team meeting

Qualifications

Qualifications:

• Bachelor of Science in Nursing (BSN) preferred or the equivalent combination of training and experience, plus 3-5 years of related experience.

• Registered Nurse clinical license required.

• UM Certification (InterQual), Certified Case Manager preferred.

• 1-2 years' experience in a payer setting preferred.

• 1-2 years' experience in acute care setting preferred.

• Bilingual language skills desirable.

Skills/Competencies

• Demonstrate MGB Health Plan's core brand principles of always listening, challenging conventions, and providing value.

• Strong aptitude for technology-based solutions.

• Embrace opportunities to take the complexity out of how we work and what we deliver.

• Celebrate diversity and create an environment where it can fearlessly thrive.

• Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation

• Ability to inject energy, when and where it's needed.

• Respect the talent and unique contribution of every individual, and treat all people in a fair and equitable manner.

• Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.

• Be accountable for delivering high-quality work. Act with a clear sense of ownership.

• Bring fresh ideas forward by actively listening to and working with employees and the people we serve.

EEO Statement

Mass General Brigham Health Plan 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.