Director, Utilization Management

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities.

At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

The experience expected from applicants, as well as additional skills and qualifications needed for this job are listed below.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here (https : / / youtu.be / S5I HgoecJQ).

Job Summary

The Director, Utilization Management is responsible for directing, leading, and modifying the business processes and operations for all levels of utilization management review (i.

e., Precertification and Intake Services, Inpatient & Outpatient) for Point32Health’s lines of business. The Director is responsible for ensuring achievement of Point32Health corporate goals;

compliance with Point32Health business rules; oversight of all aspects of outpatient services utilization management; and development, implementation and refinement of effective business processes that support compliance with relevant regulatory requirements (such as CMS, DOI, NCQA, ACA, USFHP and / or ASO / ERISA).

The Director is expected to strategically develop and effectively deploy solutions in support of corporate and division specific goals.

She / he will do so in an engaged and professional manner within and through a matrixed business environment. The Director will collaborate with division and enterprise business and medical leadership to drive clinical and / or operational initiatives.

The Director is expected to collaborate with other Health Care Services peers / leaders, Operations and / or divisional department clinical leaders (such as the divisional CMO, Medical Directors, Directors and / or business leads), plan medical staff and key provider facility and physician or group clinical leadership.

The Director oversees and leads medical management activities related to precertification utilization management and discharge planning for acute inpatient, LTAC (Long-term Acute Care), rehabilitation and skilled nursing services.

The Director ensures initiatives are on schedule and within budget, and guides strategy, policies, and protocols in accordance with organizational strategy.

The Director will ensure collaboration and coordination with enterprise or divisional based behavioral health and / or case management leaders and programs.

The Director assumes a leadership role with internal and external customers to achieve optimal clinical and resource outcomes.

Key Responsibilities / Duties what you will be doing

• Oversee and lead the precertification management and related authorization management operations for Commercial, Senior and Public Plans (MassHealth and QHP (Qualified Health Plan)) products.
• Effectively collaborate with divisional Chief Medical Officers, enterprise Medical Directors, enterprise and division based Behavioral Health leaders to support appropriate utilization of health care services and quality of care for all products.
• Lead or support medical trend management initiatives in partnership with senior leaders for Health Care Services, Commercial and Public Plans divisions.
• Develop, implement, and oversee business processes to ensure compliance with all federal and state regulatory and accreditation requirements and Point32Health business rules.
• Ensure that appropriate key performance and outcomes measures are in place, monitored and utilized for program assessment and program management.
• Oversee and lead effective relationships development between Point32Health and the facility / provider community.
• Actively participate in and / or lead workgroups and steering committees to identify, plan and implement Point32Health strategic expansion initiatives, utilization management and / or clinical operations strategies.
• Represent Point32Health and Health Care Services to internal and external clients regarding clinical operations, utilization management, complex or unique client systems being designed or revised, and program performance for client specific SLAs (service level agreements) / KPIs (key performance indicators).
• Recruit, hire, educate, and evaluate staff.
• Guide and enhance the professional development of reporting staff. Provide coaching, feedback, and direction to ensure the successful achievement of business and professional goals.

Support effective operational techniques while promoting customer satisfaction and operational efficiency in all areas of accountability.

• Plan budget and oversee management of department resources.
• Participate as a key member in the Clinical Services Management Team. Represents Health Care Services and / or Clinical Services in relevant corporate teams.
• Other projects and duties as assigned.

Qualifications what you need to perform the jobEducation, Certification and Licensure

• BS / BSN (Bachelor of Science in Nursing) required.
• RN (Registered Nurse) with unrestricted MA license required.
• Certification in Utilization Management beneficial but not required.

Experience (minimum years required) :

• 10+ years of progressive and responsible operations experience in managed care and / or health plan systems, at least four (4) of which are at management level.
• Experience with operations of commercial (fully funded and self-funded), exchange, Medicaid and Medicare products required.
• Experience in managed care systems required.
• Ideal candidate will have extensive, relevant inpatient and / or medical management experience with a strong operation background.

Skill Requirements

• Must have a proven ability to achieve goals and deliver bottom line results.
• Excellent working knowledge of managed care operations and business processes is essential, with key expertise in the areas of inpatient management and proven competence in directing operational compliance with CMS regulatory and NCQA, URAC (Utilization Review Accreditation Commission) or DOI (Division of Insurance) requirements.
• Proven ability to successfully lead staff is required.
• Work cooperatively as a team member across multiple levels within the organization.
• Results orientation - drives to meet business-driven goals.
• Ability to handle multiple demands-must be able to balance multiple competing initiatives / interests.
• Requires the ability to think and plan strategically.
• Systems thinking must understand overall Point32Health systems / people and the internal and external impact of business changes.
• Influencing others particularly those outside of direct reporting relationships.
• Strong communications skills (formal and informal, written and verbal).
• Coaching and Mentoring - primarily of direct reports, but also of others.
• The ideal candidate will be a high energy personality type who can mobilize a staff around a goal or set of goals and achieve it;

is able to sustain high levels of activity over long hours when necessary and has the mental energy to constantly seek better alternatives.

Requires focus on process engineering and improvement; discern larger patterns and relationships from smaller components and develop and implement work plans through to application.

Frequent contact with senior leadership, physicians, managers, and peers necessitates excellent interpersonal and communication skills.

A high level of diplomacy is necessary to anticipate, recognize, and deal effectively with politically sensitive issues.

Excellent leadership skills are needed to guide and inspire others; encourage high standards and exemplify those standards;

command attention and respect. Role requires change management and team engagement skills, including the ability to build coalitions across disciplines and departments throughout the company.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel) :

• Valid drivers’ license and ability to provide transportation.
• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone / headset and PC / keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification.

They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position.

Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes :

• Medical, dental and vision coverage
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https : / / www.point32health.org / careers / benefits /

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do from product design to the workforce driving that innovation.

Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts.

Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent.

We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

At Point32Health, we strive to be a different kind of nonprofit health and well-being company, with a broad range of health plans, and innovative tools that make navigating health and well-being easier, guiding our members at every step of their health care journey to better health outcomes.

We are committed to providing high-quality and affordable health care, improving the health and wellness of our members, and creating healthier communities across the country.

The Point32Health name is inspired by the 32 points on a compass. It speaks to the critical role we play in guiding and empowering the people we serve to achieve healthier lives.

Our employees are hard-working, innovative, and collaborative. They look for opportunities to grow and make a difference, and they help make us strive to be one of the Top Places to work in New England.

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