Manager of Utilization Management
About The Position
Baystate Health’s Health New England is seeking a Manager of Utilization Management to lead its Utilization Management Health Services Team in delivering high-quality, cost-effective, member-centered care. This manager leads registered nurses and clinical support professionals and oversees utilization management services across Commercial, Medicare, and Medicaid lines of business. In partnership with the Medical Director and organizational stakeholders, the role drives quality improvement, operational performance, regulatory compliance, and strategies intended to positively impact member outcomes. This is a fully remote position. Candidates must reside in Massachusetts or Connecticut. The schedule is Monday through Friday, either 8:00 a.m.–4:30 p.m. or 9:00 a.m.–5:30 p.m. There are no weekend or holiday shifts; occasional evening meetings may occur. The listed base salary range is $108,180–$147,097, with a midpoint of $124,342. The employer notes that new hires typically start in the lower part of the range and that actual pay depends on relevant experience.
Requirements
- Bachelor’s degree in Nursing.
- Active Registered Nurse license in Massachusetts.
- At least 5 years of progressively responsible case management and/or utilization management experience.
- Demonstrated leadership and negotiation experience.
- Project management experience.
- Strong knowledge of state licensure, regulatory requirements, and NCQA accreditation standards.
- Knowledge of data collection, analysis, and presentation methods.
- Familiarity with Medicare and Medicaid benefits and regulatory requirements.
- Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Access.
- Excellent written, verbal, presentation, and problem-solving skills.
- Ability to work independently, establish priorities, manage competing demands, and adapt to changing organizational needs.
- Must reside in Massachusetts or Connecticut.
Nice To Haves
- Nursing Informatics certification from the American Nurses Credentialing Center.
Responsibilities
- Manage, mentor, and develop registered nurses and non-licensed clinical support staff.
- Monitor team performance, set expectations, and provide coaching, training, and continuing education.
- Identify operational challenges and implement corrective action plans and performance improvements.
- Promote consistent processes, accountability, and professional development across the department.
- Oversee utilization management processes across Commercial, Medicare, and Medicaid lines of business.
- Partner with the Medical Director to develop Quality Improvement Activities and oversee Delegation Agreements.
- Evaluate clinical treatment criteria and ensure staff are appropriately trained in their application.
- Use data to measure outcomes, identify trends, monitor performance, and recommend improvement opportunities.
- Develop and implement processes that support positive member outcomes and responsible healthcare cost management.
- Monitor compliance with NCQA, MCRA, and other applicable regulatory requirements.
- Serve as relationship manager for assigned vendors, providing oversight and supporting effective partnerships.
- Collaborate with Provider Relations, Healthcare Economics, Sales, Member Services, Claims, ASO, and other internal teams.
- Support project and product implementations and assist in evaluating new technologies and applications.
- Maintain the Health Services Operations Manual in partnership with department leadership.
- Present updates, findings, and recommendations to executive leadership, management, and peers.
- Lead department participation in the Manager-Led Problem Solving process.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
