Utilization Management Transitions of Care Coordinator

Mass General Brigham•Somerville, MA

5d•Remote

About The Position

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. The role is an integral part of our clinical coordination team, providing support to providers, facilities, and members to ensure a streamlined and timely transition from one level of care to another. This position will serve as the single point of contact for facilities and providers when a member requires specialized support, when complex or difficult discharge and transition plans are in place, or when barriers to accessing the next appropriate level of care arise. Candidates must demonstrate a strong understanding of levels of care across the continuum, including inpatient acute hospital care, step-down settings, and post-acute services such as skilled nursing facilities, inpatient rehabilitation, long-term acute care, and home-based care. Experience navigating transitions from hospital settings to post-acute environments is essential. In addition, candidates must have a solid managed care understanding, including how authorizations, utilization management criteria, medical necessity, and benefit structures impact transitions of care and placement decisions. This role will track long-stay members and proactively support movement to the next appropriate level of care, collaborating closely with Utilization Management, Appeals and Grievance, Care Management, and Medical Director teams to resolve clinical, operational, and payer-related barriers to successful transitions.

Requirements

Associate's Degree Nursing required or Bachelor's Degree Healthcare Administration required or Bachelor's Degree Related Field of Study required
Massachusetts Registered Nurse [RN] license required
At least 2-3 years of experience in health plan clinical services/utilization management required
At least 2-3 years of clinical experience required
Strong analytical and critical thinking skills.
Excellent verbal and written communication abilities.
Proficient in using electronic health records (EHR) and billing systems.
Detail-oriented with strong organizational skills.
Ability to handle sensitive information with confidentiality and professionalism.
Strong interpersonal skills to work effectively with various stakeholders.

Responsibilities

Ensures that transitional needs and barriers are resolved in a timely manner to meet regulatory timeframes.
Directly interact with providers and their staff to obtain additional clinical information, as well as with members or their advocates to understand the full need to transition a member from one level of care to another.
Review information and provide recommendations to the collaborative team based on analysis of the clinical material.
Tracks and monitors the status of long-stay inpatient/post-acute cases, ensuring timely discharge planning.
Identifies trends and patterns in discharge barriers with facilities and providers.
Coordinates communication between patients, healthcare providers, and insurance companies regarding discharge needs.
Coordinates communication with state and federal partners to ensure length of stay reporting is timely and accurate, and delivers follow-up information, as requested, by line of business or regulatory partners.
Participates in interdisciplinary meetings to discuss complex cases and recommend solutions.