Manager, Medicare Advantage Coordinated Care

Mass General Brigham•Somerville, MA

1d•Hybrid

About The Position

Responsible for providing leadership and oversight for care coordination and case management services within MGB Health Plan's Medicare Advantage line of business. This role ensures effective, patient-centered coordination of care across the continuum, supporting quality outcomes, safe transitions, and appropriate utilization of resources. The manager collaborates closely with interdisciplinary teams to improve care delivery and promote best practices in case management, discharge planning, and population health.

Requirements

Bachelor's Degree required
Massachusetts Registered Nurse (RN) required
At least 5-7 years of experience in care coordination, case management, or discharge planning in a healthcare setting required
At least 2-3 years of experience in a supervisory or leadership required
In-depth knowledge of case management standards, patient care coordination strategies, and healthcare regulations.
Strong leadership, team-building, and staff development skills.
Excellent communication, problem-solving, and negotiation abilities.
Ability to analyze data, identify trends, and implement process improvements.
Proficiency in electronic health records (EHRs), case management systems, and reporting tools.

Nice To Haves

Master's Degree preferred
At least 1-2 years of experience with utilization review, value-based care, population health, managed care principles, transitional care models, and interdisciplinary care planning preferred
Experience working for a health plan supporting its Medicare Advantage line of business highly preferred
Experience preparing for CMS audits highly preferred

Responsibilities

Oversee daily operations of care coordination and case management teams, including registered nurses, social workers, and support staff.
Ensure timely and effective coordination of patient care plans, including discharge planning, transition of care, and resource referrals.
Monitor workflows to support appropriate utilization review, medical necessity determinations, and regulatory compliance.
Collaborate with clinical leadership, physicians, and external providers to resolve barriers to care and optimize patient flow.
Develop and maintain policies, procedures, and workflows that align with industry standards, payer requirements, and internal goals.
Manage performance metrics, including readmission rates, length of stay, denial rates, and patient satisfaction outcomes.
Facilitate staff education, training, and professional development, support certification in case management and care transitions.
Represent care coordination in interdisciplinary committees, quality improvement initiatives, and accreditation readiness efforts.
Ensure compliance with CMS, Joint Commission, and other applicable regulations and standards.