Director, Inpatient UM

Director, Inpatient Utilization Management

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

The Director, Inpatient Utilization Management is responsible for directing, leading, and modifying the business processes and operations for utilization management (UM) review to ensure achievement of Point32Health corporate goals; compliance with Point32Health business rules; oversight of all aspects of outpatient services utilization management; and development, implementation and refinement of effective business processes that support compliance with relevant regulatory requirements (such as CMS, DOI, NCQA, ACA, USFHP and/or ASO/ERISA). The Director is expected to strategically develop and effectively deploy solutions in support of corporate and division specific goals. She/he will do so in an engaged and professional manner within and through a matrixed business environment. The Director will collaborate with division and enterprise business and medical leadership to drive clinical and/or operational initiatives. The Director is expected to collaborate with other Health Care Services peers / leaders, Operations and/or divisional department clinical leaders (such as the divisional CMO, Medical Directors, Directors and/or business leads), plan medical staff and key provider – facility and physician or group – clinical leadership. The Director oversees and leads medical management activities related to utilization management and discharge planning for acute inpatient, LTAC (Long-term Acute Care) rehabilitation and skilled nursing services. The Director ensures initiatives are on schedule and within budget, and guides strategy, policies, and protocols in accordance with organizational strategy. The Director will ensure collaboration and coordination with enterprise or divisional based behavioral health and / or case management leaders and programs. The Director assumes a leadership role with internal and external customers to achieve optimal clinical and resource outcomes.

Key Responsibilities/Duties

• Oversee and lead the precertification management and related authorization management operations for Commercial, Senior and Public Plans (MassHealth and QHP (Qualified Health Plan)) products.
• Effectively collaborates with divisional Chief Medical Officers, enterprise Medical Directors, enterprise, and division based Behavioral Health leaders to support appropriate utilization of health care services and quality of care for all products.
• Lead or support medical trend management initiatives in partnership with senior leaders for Health Care Services, Commercial and Government Market divisions.
• Develop, implement, and oversee business processes to ensure compliance with all federal and state regulatory and accreditation requirements and Point32Health business rules.
• Ensure that appropriate key performance and outcomes measures are in place, monitored and utilized for program assessment and program management.
• Oversee and lead effective relationships development between Point32Health and the facility / provider community.
• Actively participate in and/or lead workgroups and steering committees to identify, plan and implement Point32Health strategic expansion initiatives, utilization management, and/or clinical operations strategies.
• Represent Point32Health and Health Care Services to internal and external clients regarding clinical operations, utilization management, complex or unique client systems being designed or revised, and program performance for client specific SLAs (service level agreements) / KPIs (key performance indicators).
• Recruit, hire, educate, and evaluate staff.
• Guide and enhance the professional development of reporting staff. Provide coaching, feedback, and direction to ensure the successful achievement of business and professional goals. Support effective operational techniques while promoting customer satisfaction and operational efficiency in all areas of accountability.
• Plan budget and oversee management of department resources.
• Participate as a key member in the Utilization Management Team. Represents Health Care Services in relevant corporate teams.
• Other projects and duties as assigned.

Qualifications – what you need to perform the job

Certification and Licensure

RN (Registered Nurse) with unrestricted MA license preferred

Certification in Utilization Management is beneficial but not required

Education

• Required (minimum): Bachelor's degree
• Preferred: BSN (Bachelor of Science in Nursing); Master's degree

Experience

• Required (minimum): 10+ years of progressive and responsible operations experience in managed care and/or health plan systems, at least four (4) of which are at management level. Experience with operations of commercial (fully funded and self-funded), exchange, Medicaid and Medicare products required. Experience in managed care systems required. Ideal candidate will have extensive, relevant inpatient and/or medical management experience with a strong operational background.

Skill Requirements

• Must have a proven ability to achieve goals and deliver "bottom line" results.
• Excellent working knowledge of managed care operations and business processes is essential, with key expertise in the areas of inpatient management and proven competence in directing operational compliance with CMS regulatory and NCQA, URAC (Utilization Review Accreditation Commission) or DOI (Division of Insurance) requirements.
• Proven ability to successfully lead staff is required.
• Work cooperatively as a team member across multiple levels within the organization.
• Results orientation - drives to meet business-driven goals.
• Ability to handle multiple demands-must be able to balance multiple competing initiatives/interests.
• Requires the ability to think and plan strategically.
• Systems thinking – must understand overall Point32Health systems/people and the internal and external impact of business changes.
• Influencing others – particularly those outside of direct reporting relationships
• Strong communications skills (formal and informal, written and verbal)
• Coaching and Mentoring - primarily of direct reports, but also of others

The ideal candidate will be a high energy personality type who can mobilize a staff around a goal or set of goals and achieve it; is able to sustain high levels of activity over long hours when necessary and has the mental energy to constantly seek better alternatives. Requires focus on process engineering and improvement; discern larger patterns and relationships from smaller components and develop and implement work plans through application.

Frequent contact with senior leadership, physicians, managers, and peers necessitates excellent interpersonal and communication skills. A high level of diplomacy is necessary to anticipate, recognize, and deal effectively with politically sensitive issues. Excellent leadership skills are needed to guide and inspire others; encourage high standards and exemplify those standards; command attention and respect. Role requires change management and team engagement skills, including the ability to build coalitions across disciplines and departments throughout the company.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Valid drivers' license and ability to provide transportation.
• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

$166,666.40 -$249,999.60

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company's sole discretion, consistent with the law.

Point