Manager THPP UM Team Inpatient
: Job Details :

Job Summary

The Manager, Inpatient manages Utilization Management (UM) Clinicians in day to day operations of the UM Process and is responsible for medical management activities related to utilization and discharge planning for acute inpatient, LTAC, rehabilitation and skilled nursing as well as Out of Network Management. S/he is accountable for implementation, monitoring and oversight of department functions and programs and the delivery of defined metrics to validate business unit/program effectiveness. The Manager, Inpatient works collaboratively with appropriate Point32Health departments and staff to identify and address opportunities to improve service, reduce administrative cost and demonstrate outcomes for functions and programs within jurisdiction. The Manager must have working knowledge of all Point32Health product lines to provider cross coverage for other Clinical Services Inpatient Managers. The Manager works collaboratively with the divisional case management departments, contracted provider and employers to address opportunities to improve service to and optimize the business relationships, while meeting the Point32Health business and quality goals. The Manager, Inpatient partner's to support the delivery of services through integrated care teams to support an optimal wellness and care experience for the individual member. The Manager is accountable for recruitment, evaluation, management and development of Team Managers within jurisdiction. This position reports to the Senior Manager, Inpatient UM.

Key Responsibilities/Duties – what you will be doing :

Business Process Implementation and Oversight

• Accountable for development, implementation, and effectiveness of new and existing Commercial and Public Plan medical management programs for inpatient utilization and discharge planning, including but not limited to:
  • Commercial or Public Plan telephonic and onsite for utilization management across the inpatient level of care, including management of complex utilization cases in acute inpatient, LTAC (long-term acute care), skilled nursing and rehabilitation facilities
  • Development and implementation of operational measures and reporting for functions within business unit in collaboration with clinical services informatics
  • Collaborative interface with case management program leaders, supporting transition of care needs, complex discharge planning and high-risk members.
  • Collaborate with department and training resources to ensure development and maintenance of an evidenced based training program
  • Establishment of written policies and procedures pertaining to Commercial or Public Plan Utilization Management and Transition of Care/discharge planning program processes, documentation standards and activities; including but not limited to medical rounds, interfaces with Medical Director and CMOs, and partner departments such as Appeals and Grievances, Behavioral Health, Contracting / Provider Relations, Customer and Provider Services, Claims, Quality, and Precertification Operations departments.
  • Establish written policies and procedures pertaining to Commercial or Public Plans Inpatient Management to assure compliance with applicable state, federal, and regulatory and accrediting agencies, including maintaining timely audit /reporting cycles. Understands DOI (Department of Insurance), EEOHS (Executive Office of Health and Human Services), and NCQA (National Committee for Quality Assurance) requirements.
  • Ensure compliance with applicable contractual service agreements with network, vendor, and employer business partners.
  • Oversees the identification of high-risk/high-cost complex members for appropriate program case management through proactive concurrent review process.
  • Manages the function of analyzing metric driven data to determine the impact of plan policies and benefits upon the Plan, Providers, membership, and groups
  • May assist Director with staffing ratios and budget requirements for department as needed.
  • Develop, review, revise and monitor workflows and procedures to ensure that all work of the medical inpatient management team meets all compliance, regulatory and accrediting standards for NCQA, DOI and EOHHS (Executive Office of Health and Human Services) while integrating product specific management programs. Ensures consistent use of review guidelines and medical necessity guidelines.
  • Serve as a consultant and resource to Team Manager and staff for complex situations that arise around regulatory issues.
  • Demonstrates the leadership and business acumen to support Medicaid products for additional growth in other states

    Staff Development

• Provide direct oversight of Team Managers within jurisdiction.
• Guides and enhances the professional development of the team manager and staff. Provides coaching, feedback, and direction thru a development plan to ensure successful achievement of business and professional goals Assists Team Manager with coaching and mentoring skills as needed
• Guide and enhance the professional development of reporting staff.
• Collaborate on development and ensure maintenance of an evidenced based training program
• Serve as consultant and resource for complex situations.

  Resource Management

• Support budget process and oversee the management of department resources.
• Accountable for realization of department administrative budget targets.

  Corporate Participation

• Represent Clinical Services / Inpatient Management in relevant corporate teams as required.
• Implement and support fulfillment of corporate goals through defined, measurable department goals.
• Enhance employee engagement through defined initiatives and resources.
• Participate in corporate initiatives and projects within jurisdiction.
• Other projects and duties as assigned.

Qualifications – what you need to perform the job

Education, Certification and Licensure

• BS degree in nursing required
• Master's degree preferred (nursing, business, healthcare administration), or equivalent experience.
• Registered Nurse with current Massachusetts license preferred.

  Experience (minimum years required):

• 7 years' Registered Nurse, Leadership experience in managed care systems and operations.is required.
• Demonstrate sound knowledge of utilization management and case management principles.
• Experience will demonstrate a functional knowledge of utilization management within a variety of payment models. Expertise in business process changes and leading people is required.

  Skill Requirements

• Ability to work cooperatively as a team member across multiple levels within the organization
• Results orientation to meet business goals
• Critical and Analytic thinking – must understand cause and effect, internal and external impact of business changes and Point32Health information systems
• Influencing others – particularly those outside of direct reporting relationships
• Strong communications skills (formal and informal, written and verbal)
• Coaching and Mentoring - primarily of reports, but also of others
• Must have commitment to excellence in customer service
• Considers creative alternatives to traditional/conventional practices and takes risk when appropriate to the situation.
• Regard for confidential data and adherence to corporate compliance policy
• Ability to handle multiple demands--must be able to balance multiple priorities
• Initiative, sound judgment, and the ability to work under pressure in a constantly changing environment balancing multiple priorities and utilizing resources aggressively.

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

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This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R8247