Remote RN Utilization Management Manager

Baystate Noble Hospital; United States; Remote; USD 108,000 - 147,000; Full time

Job summary

Baystate Health is seeking a Manager of Utilization Management to lead the Health Services Team and shape high-quality, cost-effective, member-centered care from a remote location in MA/CT. You will oversee utilization management across Commercial, Medicare, and Medicaid with a focus on quality improvements and regulatory compliance.

Responsibilities include mentoring nurses and staff, driving performance, and partnering with leadership to implement data-driven improvements and cost-management

Qualifications

• Bachelor's 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.

Responsibilities

• Lead and develop registered nurses and clinical support staff.
• Monitor team performance and provide coaching and continuing education.
• Identify operational challenges and implement corrective action plans and performance improvements.
• Promote consistent processes, accountability, and professional development across the department.
• 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 trained in their application.
• Use data to measure outcomes, identify trends, monitor performance, and identify opportunities for improvement.
• Develop and implement processes that support positive member outcomes and responsible healthcare cost management.
• Monitor compliance with NCQA, MCRA, and other applicable regulatory requirements.

Skills

Leadership

Case management

Utilization management

Regulatory knowledge

Data analysis

Communication

Education

Bachelor's Degree in Nursing

Nursing Informatics Certification

Tools

Microsoft Excel

Microsoft Word

PowerPoint

Microsoft Access

Job description

Baystate Health is seeking a Manager of Utilization Management to lead the Health Services Team and shape high-quality, cost-effective, member-centered care from a remote location in MA/CT. You will oversee utilization management across Commercial, Medicare, and Medicaid with a focus on quality improvements and regulatory compliance.

Responsibilities include mentoring nurses and staff, driving performance, and partnering with leadership to implement data-driven improvements and cost-management