Senior Manager Medical Expense Management

UnitedHealth Group•Worcester, MA

1d•$91,700 - $163,700•Onsite

About The Position

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. Responsible for coordinating care management activities and clinical program development. Provides coordination of the overall activities of care management department. Leads the development of care management objectives, policies, plans, programs and budgets while maintaining a cost efficient and effective service, supporting the organization’s clinical practices.

Requirements

BSN
Current Massachusetts RN licensure
5+ years of relevant experience
Proven experience in coordination and management of treatment services
Demonstrated leadership ability in building teams which have worked to achieve a common goal
Knowledge of budget development and management, and collaborative multi-specialty program development and management
Knowledge of Utilization Management and Case Management
Excellent organizational, communication, and interpersonal skills
Knowledge of a variety software products such Microsoft Outlook, Word, Excel, PowerPoint, etc.
Driver’s license and access to reliable transportation

Responsibilities

Oversees Utilization and Referral programs, including acute care, skilled nursing facility and home care, achieving targeted outcomes
Integrates utilization and referral management groups. Organizes to maximize program efficiency and effectiveness. Recruits and oversees team leaders. Oversees evaluation of the clinical performance of the department and staff. Oversees the day-to-day operations of all utilization and referral management programs
Manages identification of pending high cost cases
Responsible for compliance to and meeting all NCQA requirements for delegated case management as well as being responsible for NCQA certification for utilization management
Responsible for the successful implementation of all future, delegation efforts
Manages expenditures such as utilization: inpatient, SNF, hospital outpatient expenses: ER, facility, home care, ambulance, DME, tertiary referrals and POM with Service Director, regional leadership and others, participate in clinical program development, implementation, business plans, trade-off proposals
Manages inpatient and outpatient populations to anticipate needs, optimize outcomes and cost-effective care. Implements and monitors programs focused on proactive outreach for high-risk patients
Ensures quality of department services via ongoing training of staff, case review, internal audits and inter-rater reliability audits
Interfaces and resolves issues with vendors such home health care, hospitals, nursing facilities, etc., to ensure appropriate quality of care and service is delivered to patients. Participates in research activities to establish benchmarks; stay informed about innovative programs that can be replicated at the organization
Recruits and selects members of the utilization and referral management teams to manage the needs of assigned areas of responsibility
Delegates authority and responsibility to members of the teams for the operation and coordination of the programs and services
Works with department leaders to minimize outside referrals and resolve identified barriers to care
Acts as a resource for team members as needed
Manages the business and fiscal affairs of the department, including the preparation of business plans and annual capital and operating funds budgets. Monitor and assume corrective action for variances
Establishes positive working relationships with the organization’s site staff as well as payer staffs and management
Directs and supervises assigned personnel including performance evaluations, scheduling, orientation, and training. Makes recommendations on employee hire, transfers, promotions, salary changes, discipline, terminations, and other similar actions. Resolves grievances and other personnel problems within position responsibilities
Develops and recommends, in conjunction with manager, the operating and capital budgets for the areas managed. Manages activities to assure financial goals met. Monitors expenditures for compliance to approved budget. Resolves discrepancies
Coordinates the assignment of tasks and helps resolve technical and operational problems. Evaluates the impact of solutions to ensure goals are achieved
Provides effective direction, guidance, and leadership over the staff for effective teamwork and motivation, and fosters the effective integration of efforts with clinic-wide initiatives
Participates in performance improvement initiatives and recommends procedural changes when appropriate
Ensures compliance with regulatory agencies such as DPH, etc. Develops and maintains procedures necessary to meet regulatory requirement
Ensures that assigned area comply with clinic established policies, quality assurance programs, safety, and infection control policies and procedures
Ensures adequate equipment and supplies for assigned area
Ensures compliance to all health and safety regulations and requirements
Performs similar or related duties as required or directed
Regular, reliable and predicable attendance is required
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.