Utlization Management Care Manager, RN

Davita Inc.; Somerville (MA); Remote; USD 80,000 - 100,000; Full time

Job summary

A leading healthcare provider seeks a Utilization Management Care Manager to leverage clinical expertise in assessing and approving medical service requests remotely. Expected to manage authorization processes while fostering strong relationships with internal and external customers, candidates must possess a nursing degree and relevant experience in utilization management.

Qualifications

• MA Registered Nurse (RN) with current state license required.
• 3-5 years of utilization management experience preferred.
• UM certification (InterQual) preferred.

Responsibilities

• Review authorization requests for medical services and determine eligibility.
• Manage incoming requests including patient medical records.
• Ensure compliance with program performance metrics.

Skills

Communication

Problem Solving

Customer Service

Multi-tasking

Relationship Building

Education

Associate's Degree Nursing

Bachelor's Degree Nursing

Tools

Microsoft Office

InterQual

Milliman

Job description

The Utilization Management Care Manager (UMCM) will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review as well as complete determinations following physician review.
Essential Functions
* Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within the MGB Health Plan as needed.
* Manage incoming requests for procedures and services, including patient medical records and related clinical information.
* Adherence to program, departmental and organizational performance metrics including productivity.
* Excellent communication skills both verbal and written; excellent problem-solving and customer service skills are required.
* Would need to be available for "on call" for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire.
* Must be self-directed and highly motivated with an ability to multi-task.
* Develop and maintain effective working relationships with internal and external customers
* Hold self and others accountable to meet commitments.
* Ensure diversity, equity, and inclusion are integrated as a guiding principle.
* Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
* Build strong relationships and infrastructures that designate MGB Health Plan as a people-first organization.

Education

• Associate's Degree Nursing required or Bachelor's Degree Nursing preferred

Licenses and Credentials

• MA Registered Nurse (RN) with a current state license required

Experience

• At least 3-5 years of utilization management experience is highly preferred
• UM certification (InterQual) preferred
• At least 1-2 years of experience in a payer setting highly preferred
• Experience using InterQual/Milliman preferred

Knowledge, Skills, and Abilities

• Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
• Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
• Ability to establish strong rapport and relationships with patients and staff.
• Proficient in Microsoft Office and industry related software programs.
• Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
• Ability to maintain client and staff confidentiality.
• Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.
• Knowledge of Healthcare and Managed Care preferred.

Working Conditions

• This is a remote role that can be done from most US states. It will require occasional time at the office (roughly 1x/quarter) for team meetings in Somerville, MA

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.