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