Medicare And Medicaid Utilization Management Care Manager, Remote

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 Medicare and Medicaid 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.

Essential Functions
   Strong knowledge of Medicare regulatory requirements including Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs)
   Strong knowledge of Medicaid/MassHealth regulatory requirements 
   Expertise in clinical review for prospective, concurrent, retrospective Utilization Management reviews utilizing Interqual , company policies and procedures, and other resources as determined by review, including physician reviews as needed for all lines of business as per departmental needs
   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 verbal and written communication skills. 
   Excellent problem solving and customer service skills.  
   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
   Hold self and others accountable to meet commitments.
   Sound decision making and time management skills.
   Proactive in areas of professional development personally and for the department.
   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.
   Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual , Outlook, SharePoint, PC based operating system, and web-based phone system.    Experience with clinical applications/systems.
   Other duties as assigned with or without accommodation.

Working Conditions and Physical Effort 
   Work is normally performed in a typical remote office work environment. 
   Able to stand and sit for periods of time as needed to perform work related functions 
   Ability to use a laptop/computer, manual dexterity, headset use
   Lift up to 25 lbs
   Work is performed in a remote setting but may require travel to in-office location if technical difficulties inhibit job performance or as required for meetings
   Require work after schedule work hours, nights and weekend as the business need requires    

Knowledge and Education    

Required:
   Registered Nurse Clinical License
Preferred/Desired:
   Bachelor of Science in Nursing (BSN)
   UM Certification (InterQual)
   Certified Case Manager (CCM)

Experience    

Required:
   3-5 years of MA UM experience.
   Experience using Interqual /Milliman
Preferred/Desired:
   1-2 years experience in a payer setting
   1-2 years experience in acute care setting 

Skills/Competencies    

   Demonstrate Mass General Brigham Health Plans' 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
   Current in healthcare trends.
   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.
   Communicate respectfully and professionally with colleagues
   Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.

Other Skills    

Bilingual language skills desirable

Action 
Application of policies, procedures and evidence based criteria for authorization reviews