Medicaid Supervisor, Utilization Management
Mass General Brigham Health Plan

Job Info

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This is a remote role with occasional (roughly 1x/every other month) onsite team meetings in Somerville, MA.

The Medicaid Supervisor will work closely with the Utilization Manager of Clinical Services to oversee the daily operations of the Utilization Management (UM) Staff. The incumbent will be responsible for the direct coaching, supervision, and evaluation of licensed clinical and non-clinical staff in various roles. The incumbent will be required to participate in various meetings and agile groups for the business needs.

ESSENTIAL FUNCTIONS
• Strong knowledge of Medicaid regulatory requirements including Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs)
• Expertise in clinical inpatient and outpatient utilization management reviews utilizing Interqual ®, company policies and procedures, and other resources as determined by review, including physician reviews as needed
• Expertise in clinical inpatient and outpatient care
• Demonstrated leadership skills to influence and motivate a team, team-building skills, and performance coaching
• Ability to organize and effectively manage meetings
• Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual ®, Outlook, SharePoint, PC-based operating systems, and web-based phone system
• Excellent verbal, written, listening, and interpersonal skills
• Ability to efficiently prioritize and organize work
• Ability to be creative, develop solutions for problem-solving, and utilize critical thinking skills
• Strong internal and external customer focus
• Demonstrated commitment to increasing customer satisfaction
• Demonstrated collaborative working efforts within the UM department and external business partners
• Ability to follow directions and work with minimal direct supervision
• Sound decision-making and time-management skills
• Proactive in areas of professional development personally and for the department
• Outstanding project management skills and techniques

Core Functions:
• Staff Supervision
• Educate staff on quality review requirements and documentation guidelines, with emphasis on highly accurate and specific documentation consistent with national regulations and practice
• Monitor individual productivity and adjust assignments as needed to support productivity goals, quality reviews, ensure timeliness, and equitable distribution of cases
• Report staff productivity trends and any other department/staff concerns to manager as needed
• Promote staff growth and development
• Lead staff orientation and training within the UM department
• Staff performance management, conduct 1:1 meetings with staff
• Regular internal and external communication on a team and individual basis
• Oversee compliance and timeliness of denial letters
• Participate in and lead agile groups
• Participate in and lead quality improvement initiatives within the clinical operations department
• Participate in monthly audits, providing feedback to staff as opportunities for improvement as identified

Infrastructure Enhancement
• Participate in system enhancement planning & development
• Policy & Procedure implementation and maintenance
• Ensure site assignments, phone/fax lists, hospital reports, etc are updated and accurate
• Monthly review of staff roles, metrics, and quality of work, making readjustments to align with Medicaid regulations and MGB Health Plan goals as needed
• Develop tools and workflows to ensure the accuracy and completeness of reviews and documentation
• Participate in inter-departmental meetings
• Inform, engage, inspire, motivate, and actively listen to employees.
• Make decisions that put the needs of the people we serve-our members, providers, brokers, and employers-front and center.
• Communicate and cascade information to employees in a timely manner and actively participate in the success of cross-organizational programs and initiatives.
• Identify/create processes and align resources to accomplish key objectives; clearly convey and assign clear accountability for important objectives, deadlines, and expectations.
• Hire, participate in, and/or recommend development measures and disciplinary actions up to and including termination; evaluate performance and supervise the work of all direct and indirect reports following established organizational policies, procedures, and practices.
• Set clear goals and objectives, use metrics to measure performance, and hold employees accountable. Provide coaching to improve performance and hold regular development meetings.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.
• Hold self and others accountable to meet commitments.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles or setbacks.
• Build strong relationships and infrastructures that designate MGB Health Plan as a people-first organization.
• Other duties as assigned with or without accommodation.

WORKING CONDITIONS AND PHYSICAL EFFORT
• Able to stand and sit for periods of time as needed to perform work-related functions
• Ability to use a laptop/computer, manual dexterity, headset use
• Work is performed in a remote setting but may require travel to an in-office location if technical difficulties inhibit job performance or as required for meetings
• Require work after scheduled work hours, nights, and weekends as the business needs requires

Qualifications
QUALIFICATIONS

• Massachusetts Registered Nurse clinical license, Certified Case Manager (CCM) preferred
• Bachelor of Science in Nursing (BSN)
• At least 3-5 years of experience in a managed care setting
• Medicaid experience required, expert knowledge of utilization management (i.e. Health Center, Hospital, Insurance Company), team leadership/management experience required

SKILLS/COMPETENCIES

• Microsoft Excel, Word, PowerPoint, Outlook, McKesson InterQual, SharePoint, QNXT a plus Demonstrate MGB Health Plan's core brand principles of always listening, challenging conventions, and providing value.
• Bring fresh ideas forward by listening to and working with employees and the people we serve.
• Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner.
• Strong, demonstrated track record of an ability to execute on time, on budget, and on scope.
• Strong aptitude for technology-based solutions.
• Ability to inject energy, when and where it's needed.
• Current in healthcare trends.
• Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be."
• Ability to develop, introduce, defend, and gain support for new ideas and approaches.
• Excellent leadership skills and leadership track record.
• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience; strong executive presence, presentation, and communication skills. Strong verbal, active listening and written communication skills required.
• Ability to view the long-range trends and cycles of the business and industry and see the "big picture."
• Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.
• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.
• Excellent interpersonal skills, including the ability to influence others at all levels of an organization.
• Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
• Unquestionable integrity.

OTHER SKILLS

Bilingual language skills desirable

ACTION
• The supervisor is responsible for approving paid time off (PTO)
• Staff assignments
• Managing frequency and need for staff meetings, scheduling, and development of the agenda
• Frequency and need for staff training, scheduling, and development of the training
• Coaching and mentoring staff
• Creating desktop procedures

ORGANIZATIONAL RELATIONSHIPS/SCOPE
The Medicaid supervisor reports to the clinical manager in the Utilization Management Department of Clinical Services. This supervisor may be responsible for supporting other supervisors within the department and coverage of delegated work from the clinical manager.

The supervisor will manage a staff of 8.

ABOUT US:

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.

We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.

EEO Statement
Mass General Brigham Health Plan 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.

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