The Utilization Management Supervisor, Senior Care Options is a key member of our Dual-eligible Special Needs Plan (DSNP) Senior Care Options product medical management team. The Supervisor is responsible for the daily supervision and operations of the SCO Utilization Management team as the team carries out the requirements of the SCO Model of Care and the contractual requirements of CMS and MassHealth.
The Supervisor may carry a caseload based on business needs. This caseload will include the management of prior authorization of services, where required, and concurrent review of inpatient stays. The Supervisor collaborates regularly with the Director of Utilization Management, Plan Medical Directors, SCO Care Management staff and other SCO team members, members’ PCPs, requesting providers, and facility care management staff.
•Collaborates with the SCO Care Management team, the LTSS Manager, ASAP vendor manager, SCO trainer.
•Participates in staff hiring, work allocation, training, performance management in collaboration with the Director of UM, professional development and related supervisory functions.
•Consults with the Director of UM, clinical trainers, and staff to identify/implement workflow and process improvements to maximize quality, efficiency and cost effectiveness of the team.
•Assists with and participates in the planning, development and implementation of SCO UM department specific and cross functional projects.
•Support UM initiatives through communication strategies, team leadership, facilitation and recommendations.
•Responsible for tracking interventions to address opportunities for improvement in overall UM performance.
•Under the direction of and in collaboration with the Director of UM, develops and uses metrics and management reports to monitor staff productivity, quality, and efficiency.
•Accountable for timely notification to the Director if performance falls below expectations, and works with leadership to develop an improvement plan to improve.
•Identifies members who could benefit from multidisciplinary rounds.
•Enters data accurately, timely, and completely; documents all encounters according to the department policies and workflows and complies with contractual requirements regarding turn-around-times.
•Conducts routine staff audits to monitor compliance with workflows, job aids, and activities.
•Maintain caseload volume and turnaround times meeting department productivity standards, as per collaboration with Director and per business need.
•Provides high level of service and satisfaction to internal and external customers.
•Monitors case inventory and team members’ workload and adjusts as necessary.
•Responds to issues and concerns raised by staff and escalates to management as appropriate.
•In conjunction with clinical trainers, assists with orientation including development of training materials as it relates to SCO UM.
•Maintains current knowledge of medical necessity criteria, SCO benefits, the Plan’s utilization related policies and procedures, etc.
•Collaborates with SCO operations team regarding impact of utilization management policies and procedures on other operational areas, such as Claims; participates in SCO SWOT meetings, as requested.
•Other duties as assigned.
•Nursing degree or diploma required. Bachelor’s Degree in Nursing (BSN) preferred
•Master’s Degree in Nursing or related field
•Certified Coding Professional (CPC) or other medical coding certification
•1 year of prior supervisory experience
•5 years Registered Nurse experience, including 2 years direct care services and 3 years of any combination of utilization management, discharge planning in an acute care setting, or health plan clinical operations experience at a staff level
•2 years health plan operations experience with Medicare and/or Medicaid populations, senior care options population highly desirable
•Health plan operations, experience interacting with providers highly desirable
•Experience managing exempt and non-exempt staff preferred
•Knowledge of or experience with community support services
LICENSURE, CERTIFICATION OR CONDITIONS OF EMPLOYMENT:
•Active unrestricted RN License
•Pre-employment background check
•Ability to take after hours call, including evening/nights/weekends
COMPETENCIES, SKILLS, AND ATTRIBUTES:
•Strong oral and written communication skills;
•Ability to interact within all levels of the organization as well as with external parties
•Strong working knowledge of Microsoft Office products
•Demonstrated organization and time management skills
•Strong analytical and clinical problem solving
•Ability to prioritize work
Internal Number: 2013647
About Boston Medical Center HealthNet Plan
Imagine working for an organization committed to making a difference. Founded in 1997 by Boston Medical Center (BMC), BMC HealthNet Plan supports the mission of BMC by providing medical care access to the underserved, disabled, elderly and other vulnerable populations.
BMC HealthNet Plan is a not-for-profit, market leading managed care organization that offers health insurance coverage to low-to-moderate income individuals in Massachusetts and New Hampshire (where it is known as Well Sense Health Plan). We offer health insurance plans in the Medicaid and commercial markets, and contract with health care providers and hospitals throughout Massachusetts and New Hampshire.
We employ over 600 individuals in Charlestown, Massachusetts and Manchester, New Hampshire. We offer our employees highly competitive benefits, compensation package and flexible work arrangement options. To demonstrate our commitment to serving the community, our employees are entitled to eight hours of paid volunteer time per year.
BMC HealthNet Plan employees are a diverse, talented workforce that work together to represent our values – member focus, stewardship, partnership, quality, inclusion and integrity.