Site: Mass General Brigham Health Plan Holding Company, Inc.
Job SummaryGiven equity, this position will pay somewhere between $90,000 to $107,000 annually.
The UMCM will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review, as well as complete determinations following physician review. The ideal candidate will have prior authorization experience in a managed care setting with Medicaid/ACO health plan knowledge.
Principal Duties and Responsibilities:
• Expertise in clinical review for prospective, concurrent, retrospective utilization management reviews utilizing Interqual ®, company policies and procedures, and other resources as determined by review, including physician reviews as needed for all lines of business as per departmental needs
• Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within Mass General Brigham Health Plan as needed.
• Manage incoming requests for procedures and services, including patient medical records and related clinical information.
• Strong working knowledge of commercial, self-insured, fully insured and limited network plans.
• Adherence to program, departmental, and organizational performance metrics, including productivity.
• Excellent verbal and written communication skills.
• Excellent problem-solving and customer service skills.
• Would need to be available for "on call" for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire.
• Must be self-directed and highly motivated with an ability to multi-task.
• Develop and maintain effective working relationships with internal and external customers
• Hold self and others accountable to meet commitments.
• Sound decision-making and time management skills.
• Proactive in areas of professional development, personally and for the department.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
• Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual ®, Outlook, SharePoint, PC based operating system, and web-based phone system.
QualificationsEducation- Associate's Degree Nursing required or Bachelor's Degree Nursing preferred
Licenses and Credentials- Massachusetts Registered Nurse (RN) license required
Experience- At least 2-3 years of utilization review experience is highly preferred
- Experience using Interqual or Milliman is highly preferred
- At least 1-2 years of experience in a payer setting is highly preferred
- At least 1-2 years of experience in an acute care setting is highly preferred
Knowledge, Skills, and Abilities- Demonstrate Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value
- Strong aptitude for technology-based solutions.
- Embrace opportunities to take the complexity out of how we work and what we deliver.
- Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation
- Current in healthcare trends.
- Ability to inject energy, when and where it's needed.
- Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
- Be accountable for delivering high-quality work. Act with a clear sense of ownership.
- Bring fresh ideas forward by actively listening to and working with employees and the people we serve.
- Communicate respectfully and professionally with colleagues
- Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
Additional Job Details (if applicable)Working Conditions- Would need to be available for "on call" for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire.
- This is a remote role with occasional onsite team meetings in Somerville, MA.
Given equity, this position will pay somewhere between $90,000 to $107,000 annually.
Remote TypeRemote
Work Location399 Revolution Drive
Scheduled Weekly Hours40
Employee TypeRegular
Work ShiftDay (United States of America)
Pay Range$58,656.00 - $142,448.80/Annual
Grade98TEMP
At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.
