Manager, Medicare and DSNP Utilization Management

Job SummaryResponsible 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 FunctionsSupervise 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.QualificationsEducationBachelor's Degree requiredMaster's Degree in a related field of study (preferred)Licenses and CredentialsMassachusetts Registered Nurse (RN) license requiredExperienceAt least 3–5 years of experience in clinical care coordination or case management requiredLong-Term Services and Supports (LTSS) experience preferredAt least 2–3 years in a supervisory or leadership role requiredAt least 2–3 years of Medicare and DSNP UM experience requiredKnowledge, Skills, and AbilitiesStrong leadership and team management skillsExcellent communication and interpersonal skillsAnalytical skills to assess patient care data and identify areas for improvementProblem-solving abilities to address complex care coordination issues and implement effective solutionsKnowledge of regulatory requirements and industry best practices in clinical care and case managementProficiency in healthcare management software and electronic health record systemsWorking ConditionsRemote role; team meets quarterly at Assembly Row, Somerville (attendance encouraged)Work Location399 Revolution DriveScheduled Weekly Hours40Employee TypeRegularWork ShiftDay (United States of America)Pay Range$99,465.60 – $141,804.00 AnnualEEO Statement0100 Mass General Brigham Incorporated 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 reasonable accommodation for all individuals with a disability to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.J-18808-Ljbffr