Utilization Management Manager

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🕒 Outubro 30

🦌 Connecticut, Massachusetts – Remoto

🦌 Connecticut – Remote 🍂 Massachusetts – Remote

💵 $108.180 - $147.097 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

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Baystate Health

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1873

🏥 Saúde

🧘 Bem-estar

📚 Educação

Healthcare • Wellness • Education

Baystate Health é um sistema integrado de saúde regional que atende a região oeste de Massachusetts, oferecendo cuidados hospitalares e ambulatoriais, incluindo serviços de emergência, atendimento primário e especializado, cirurgia, oncologia, cardiologia, pediatria, radiologia e saúde materna. Opera vários hospitais e clínicas, gerencia programas de saúde e bem-estar comunitários, realiza pesquisas e ensaios clínicos, e atua como o campus regional da Faculdade de Medicina UMass Chan, com extensos programas de educação médica e de residência. A Baystate também oferece ferramentas digitais voltadas para o paciente (MyBaystate), arrecadações de fundos através de uma fundação, e iniciativas de alcance comunitário e voluntariado.

Descrição

• Lead, manage, mentor, and develop registered nurses and non-licensed clinical support staff • Monitor team performance, establish expectations, and provide coaching, training, and continuing education • Identify operational challenges and implement corrective action plans and performance improvements • Oversee utilization management processes across Commercial, Medicare, and Medicaid lines of business • Partner with the Medical Director to develop Quality Improvement Activities and oversee Delegation Agreements • Evaluate clinical treatment criteria and ensure staff are appropriately trained in their application • Use data to measure outcomes, identify trends, monitor performance, and recommend opportunities for improvement • Develop and implement processes supporting positive member outcomes and responsible healthcare cost management • Monitor compliance with NCQA, MCRA, and other applicable regulatory requirements • Manage assigned vendor relationships and support effective partnerships • Collaborate with Provider Relations, Healthcare Economics, Sales, Member Services, Claims, ASO, and other internal teams • Support project and product implementations and evaluate new technologies and applications • Maintain the Health Services Operations Manual with department leadership • Present updates, findings, and recommendations to executive leadership, management, and peers • Lead department participation in the Manager-Led Problem Solving process

🎯 Requisitos

• Bachelors Degree in Nursing, required • Active RN License in Massachusetts, required • Minimum of 5 years of progressively responsible case management and/or utilization management experience • Demonstrated leadership and negotiation experience • Project management experience • Strong knowledge of state licensure, regulatory requirements, and NCQA accreditation standards • Knowledge of data collection, analysis, and presentation methods • Familiarity with Medicare and Medicaid benefits and regulatory requirements • Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Access • Excellent written, verbal, presentation, and problem-solving skills • Ability to work independently, establish priorities, manage competing demands, and adapt to changing organizational needs • Nursing Informatics certification from the American Nurses Credentialing Center

🏖️ Benefícios

• Monday through Friday schedule • No weekends • No holidays • Fully remote position • Occasional evening meetings

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