Utilization Management Special Projects Manager

WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294325)

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Utilization Management (UM) Special Projects Manager is responsible for efficiently managing major department projects and programs with cross functional impact and significant complexity, risk and/or cost for all product lines (e.g. Medicaid, Medicare Advantage, Medicare Dual Eligible Special Needs & ACA) for the Utilization Management department. Responsibilities include meeting specific targets and goals related to people, process and data/technology. The Manager is accountable for leading and implementing multiple initiatives that impact the UM department, identifying improvement opportunities, assessing risks and communicating observations, and delivering recommendations and results to management. The Manager is also accountable for integrating the UM function with other departments’ functions including functions delegated to vendors. Additionally, the Manager will represent WellSense UM at external venues such as meetings with provider groups and state agencies as appropriate.

Our Investment in You:

• Full-time remote work

• Competitive salaries

• Excellent benefits

Key Functions/Responsibilities:

Process

• Leads and oversees the UM component of highly visible and complex initiatives (new software applications, upgrades, UM cost savings projects)

• Performs triage on escalated requests from other departments or external partners

• Key contact for inbound questions related to policy, etc.

• Develops processes for researching, follow up, and notification to requester and department staff

• Recommends updates as needed

• Leads cross-functional team to resolve issues

• Oversees the timely and accurate production of regulatory and contractual reporting

• Acts as a liaison to Legal, Compliance, Public Partnerships and Quality Departments on issues related to regulatory compliance and NCQA accreditation requirements.

• Coordinates with UM leadership team to develop corrective action plans

• Attends Medical Management Steering Committee meetings, as well as other department/organization meetings

• Maintains list of departmental policies, processes, procedures and letters, and manages review process with the business owners

People

• Collaborates effectively with UM staff, Training team, other WellSense departments, and external partners/vendors

• Acts as a change agent and leader within the UM department and across the organization

Data/Technology

• Oversees the consistent use of support technologies

• Develops reporting with Analyst by thoroughly understanding needs, purpose and requirements

• Develops departmental targets, measures and metrics and integrates their meaningful use across all department functions and team members

• Continuously evaluates tools and technologies to identify new opportunities for efficiency or effectiveness across all staff in the department

• Works with other business areas including IT, Clinical Informatics, and Quality as related to business requirement development, clinical management software configuration, and UAT

Education:

• Bachelor’s Degree in nursing, healthcare or related field or equivalent combination of education and relevant work experience

• Master’s Degree in Healthcare or related field preferred

• Lean or Six Sigma certification preferred, not required

Experience:

• 2 years experience in a Utilization Management role

• 5 years experience with Medicaid/Medicare Managed Care or other health plan experience

• 3 years experience leading health plan projects

Preferred/Desirable:

• Experience with Medicaid/Medicare recipients and community services

• CCMS, InterQual, Jiva, Facets, or other healthcare systems experience

• Health plan or insurance environment experience

• Experience with Utilization Management regulatory and accreditation requirements (e.g., NCQA, Medicaid, Medicare, ACA)Experience in an operations environment with regulatory turnaround times

• Utilization Management experience

• Experience managing cross functional projects

Licensure, Certification or Conditions of Employment:

· Holds an active license as a Registered Nurse

Competencies, Skills, and Attributes:

• Ability to manage complex processes

• Attention to detail

• Ability to meet aggressive time lines when required

• Data driven decision making

• Knowledge of metrics, and an ability to compile, format, interpret, and present data

• Mastery of verbal and written communication skills, including but not limited to the ability to translate complex subject matter into understandable information tailored to specific audiences

• Ability to successfully plan, organize, implement and manage projects within a health care setting

• Strong working knowledge of Microsoft Office applications

• Aptitude for matching business requirements to potential software solutions

• Strong analytical and problem solving skills

• Knowledge of process improvement techniques

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294325)

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According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not reach out to individuals via text, we do not ask or require downloads of any applications, or “apps”, and applicant screenings, interviews and job offers are not conducted over text messages or social media platforms. We do not ask individuals to purchase equipment for, or prior to employment. To avoid becoming a victim of an employment offer scam, please followthese tips from the FTC (https://consumer.ftc.gov/consumer-alerts/2023/01/looking-job-scammers-might-be-looking-you?utm_source=govdelivery) .