Utilization Management Manager

Job not on LinkedIn

🔥 13 hours ago

🦌 Connecticut, Massachusetts – Remote

🦌 Connecticut – Remote 🍂 Massachusetts – Remote

💵 $108.2k - $147.1k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

👻 Ghost score 0%

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Baystate Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1873

🏥 Healthcare

🧘 Wellness

📚 Education

Healthcare • Wellness • Education

Baystate Health is a regional integrated health system serving western Massachusetts, providing hospital-based and outpatient care including emergency services, primary and specialty care, surgery, oncology, cardiology, pediatrics, radiology, and maternal health. It operates multiple hospitals and clinics, runs community health and wellness programs, conducts clinical research and trials, and serves as the regional campus for UMass Chan Medical School with extensive medical education and residency programs. Baystate also offers patient-facing digital tools (MyBaystate), fundraising through a foundation, and community outreach and volunteer initiatives.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

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

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