Manager, Inpatient

Point32Health

2d • $101,217 - $151,825 • Hybrid

About The Position

The Manager, Inpatient manages Utilitzation Management (UM) Clinicians in day to day operations of the UM Process and is responsible for medical management activities related to utilization and discharge planning for acute inpatient, LTAC, rehabilitation and skilled nursing as well as Out of Network Management. S/he is accountable for implementation, monitoring and oversight of department functions and programs and the delivery of defined metrics to validate business unit/program effectiveness. The Manager, Inpatient works collaboratively with appropriate Point32Health departments and staff to identify and address opportunities to improve service, reduce administrative cost and demonstrate outcomes for functions and programs within jurisdiction. The Manager must have working knowledge of all Point32Health product lines to provider cross coverage for other Clinical Services Inpatient Managers. The Manager works collaboratively with the divisional case management departments, contracted provider and employers to address opportunities to improve service to and optimize the business relationships, while meeting the Point32Health business and quality goals. The Manager, Inpatient partner’s to support the delivery of services through integrated care teams to support an optimal wellness and care experience for the individual member. The Manager is accountable for recruitment, evaluation, management and development of Team Managers within jurisdiction. This position reports to the Senior Manager, Inpatient UM.

Requirements

• Registered Nurse with current Massachusetts license preferred.
• BS degree in nursing
• 5 years’ Registered Nurse, Leadership experience in managed care systems and operations.
• Demonstrate sound knowledge of utilization management and case management principles.
• Experience will demonstrate a functional knowledge of utilization management within a variety of payment models.
• Expertise in business process changes and leading people.
• Ability to work cooperatively as a team member across multiple levels within the organization.
• Results orientation to meet business goals.
• Critical and Analytic thinking – must understand cause and effect, internal and external impact of business changes and Point32Health information systems.
• Influencing others – particularly those outside of direct reporting relationships.
• Strong communications skills (formal and informal, written and verbal).
• Coaching and Mentoring - primarily of reports, but also of others.
• Must have commitment to excellence in customer service.
• Considers creative alternatives to traditional/conventional practices and takes risk when appropriate to the situation.
• Regard for confidential data and adherence to corporate compliance policy.
• Ability to handle multiple demands--must be able to balance multiple priorities.
• Initiative, sound judgment, and the ability to work under pressure in a constantly changing environment balancing multiple priorities and utilizing resources aggressively.

Nice To Haves

• Master’s degree (nursing, business, healthcare administration), or equivalent experience.

Responsibilities

• Accountable for development, implementation, and effectiveness of new and existing Commercial , Public Plans & Senior Products medical management programs for inpatient utilization and discharge planning.
• Development and implementation of operational measures and reporting for functions within business unit in collaboration with clinical services informatics.
• Collaborative interface with case management program leaders, supporting transition of care needs, complex discharge planning and high-risk members.
• Collaborate with department and training resources to ensure development and maintenance of an evidenced based training program.
• Establishment of written policies and procedures pertaining to lines of business.
• Conducts medical rounds, interfaces with Medical Director and CMOs, and partner departments such as Appeals and Grievances, Behavioral Health, Contracting / Provider Relations, Customer and Provider Services, Claims, Quality, and Precertification Operations departments.
• Establish written policies and procedures pertaining to all lines of business.
• Inpatient Management to assure compliance with applicable state, federal, and regulatory and accrediting agencies, including maintaining timely audit /reporting cycles. Understands DOI (Department of Insurance), EEOHS (Executive Office of Health and Human Services), and NCQA (National Committee for Quality Assurance) & CMS (Center of Medicare Services) requirements.
• Ensure compliance with applicable contractual service agreements with network, vendor, and employer business partners.
• Oversees the identification of high-risk/high-cost complex members for appropriate program case management through proactive concurrent review process.
• Manages the function of analyzing metric driven data to determine the impact of plan policies and benefits upon the Plan, Providers, membership, and groups.
• May assist Director with staffing ratios and budget requirements for department as needed.
• Develop, review, revise and monitor workflows and procedures to ensure that all work of the medical inpatient management team meets all compliance, regulatory and accrediting standards for NCQA, DOI and EOHHS (Executive Office of Health and Human Services) while integrating product specific management programs. Ensures consistent use of review guidelines and medical necessity guidelines.
• Serve as a consultant and resource to Team Manager and staff for complex situations that arise around regulatory issues.
• Demonstrates the leadership and business acumen to support Medicaid products for additional growth in other states.
• Provide direct oversight of Team Managers within jurisdiction.
• Guides and enhances the professional development of the team manager and staff. Provides coaching, feedback, and direction thru a development plan to ensure successful achievement of business and professional goals Assists Team Manager with coaching and mentoring skills as needed.
• Guide and enhance the professional development of reporting staff.
• Collaborate on development and ensure maintenance of an evidenced based training program.
• Serve as consultant and resource for complex situations.
• Support budget process and oversee the management of department resources.
• Accountable for realization of department administrative budget targets.
• Represent Clinical Services / Inpatient Management in relevant corporate teams as required.
• Implement and support fulfillment of corporate goals through defined, measurable department goals.
• Enhance employee engagement through defined initiatives and resources.
• Participate in corporate initiatives and projects within jurisdiction.
• Other projects and duties as assigned.

Benefits

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

What This Job Offers

• Job Type: Full-time
• Career Level: Manager