Medicare and Medicaid Utilization Management Care

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the worlds 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 consciously inclusive environment where diversity is celebrated. We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more. The Medicare and Medicaid 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. Essential Functions (List key responsibilities in order of importance and/or frequency.) Strong knowledge of Medicare regulatory requirements including Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) Strong knowledge of Medicaid/MassHealth regulatory requirements 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. 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 and weekends; 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. Ensure diversity, equity, and inclusion are integrated as a guiding principle. 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. Department Specific/Non-Essential Functions (List responsibilities not essential to this position.) Experience with clinical applications/systems. Other duties as assigned with or without accommodation. Working Conditions and Physical Effort (Note special physical or other demands such as lifting, standing, etc. or special working conditions such as travel, overtime, 24/7 accessibility, etc.) Work is normally performed in a typical office work environment. Able to stand and sit for periods of time as needed to perform work-related functions Ability to use a laptop/computer, manual dexterity, headset use