baystatehealth
Manager of Utilization Management
- Compensation
- Not disclosed
- Location
- Remote Work Opportunity
- Work setup
- Remote
- Seniority
- Not specified
- Employment
- Full time
- Experience
- 5+ years
- Category
- Not specified
- Posted
Skills
Must have
- Bachelors Degree in Nursing, required
- Active RN License in Massachusetts, required
- Minimum of 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.
Full description
Baystate Health’s Health New England is seeking a Manager of Utilization Management to lead our Utilization Management Health Services Team and help shape the delivery of high-quality, cost-effective, member-centered care in Springfield, MA.
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The Manager of Utilization Management leads a team of registered nurses and clinical support professionals while overseeing utilization management services across Commercial, Medicare, and Medicaid lines of business. In partnership with the Medical Director and key organizational stakeholders, you’ll drive quality improvement initiatives, strengthen operational performance, ensure regulatory compliance, and develop strategies that positively impact member outcomes.
Responsibilities:Lead and Inspire a Clinical Team
- Manage, mentor, and develop registered nurses and non-licensed clinical support staff.
- Monitor team performance, establish 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.
Drive Clinical Quality and Operational Excellence
- 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 opportunities for improvement.
- Develop and implement processes that support positive member outcomes and responsible healthcare cost management.
- Monitor compliance with NCQA, MCRA, and other applicable regulatory requirements.
Build Strategic Partnerships
- Serve as the 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.
Location:
- Fully remote position- candidate MUST reside in MA or CT