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Blue Cross Blue Shield of Massachusetts RN Manager l Registered Nurse l Utilization Management Team in Quincy, Massachusetts

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The Utilization Review RN Manager oversees a Utilization Management team, including the effectiveness of its operations, adherence to policies and procedures, associate development, performance management, and compliance. This role is responsible for monitoring and achieving individual and group metrics including cost, timeliness, and quality. The Utilization Review RN Manager focuses on providing oversight of the medical necessity review process to determine the most appropriate level of care and most cost effective site of service for the member’s needs within the scope of coverage under their available benefits. The Utilization Review RN Manager has a working knowledge of benefit and product design, regulatory and accreditation requirements, and positions their team to align with division and company business goals, maximize value to accounts, and ensure that member benefits are administered in accordance with plan requirements.

Key Responsibilities:

Management and leadership of assigned utilization management team:

  • Oversee team, providing group communications and issue escalation / resolution support

  • Serve as a mentor and advisor to utilization reviewers as they work through complex or unique cases

  • Manage and develop staff, including recruiting hiring and rewarding staff, setting performance expectations, and assessing, monitoring, and counseling staff regarding individual performance

  • Identify daily, weekly and future staffing needs and quickly adjust to fluctuating inventories and trends

  • Articulate performance expectations and establish ongoing training programs for Utilization management associates to achieve these expectations

Implementation of utilization management strategies:

  • Operationalize, implement and monitor plans in support of strategic and operational goals for the assigned Utilization Management group

  • Design and implement policies and procedures to achieve efficient use of resources and attainment of internal and external metrics

Understand and manage to key metrics (including but not limited to readmission rates, length of stay, utilization patterns and medical expense)

  • Develop and lead quality and compliance improvement programs

  • Act as a clinical liaison with other departments as needed regarding integration of programs and services, cross-functional transactions and handoffs, workflow development, system enhancement, measurement review, quality review and process improvement

Collaboration with senior management:

  • Track, analyze, interpret, and report regularly to leadership on Utilization management group performance metrics

  • Conduct audits to ensure productivity and performance are meeting or exceeding performance expectations; implement plans to address performance gaps

  • Provide management and direction to ad-hoc priorities set and projects requested by senior management

  • Drive individual and team results to program, departmental and organizational performance metrics in areas that include:

  • Staff productivity

  • E-Quality monitoring and other quality assurance indicators

  • Clinical knowledge

  • Regulatory compliance

  • Financial results

  • Foster clinical excellence by promoting and participating in continuing education initiatives

Key Technical Skills:

  • Managing in a Clinical Operations Environment (manages clinical and collaborates with non-clinical resources effectively; facilitates staff and team engagement in and accomplishment of clinical, business, and service goals in order to achieve organizational objectives)

  • Knowledge of specialized subject matter (demonstrates the use of the right resources and application of the correct policies in order to support clinical determinations and administration of benefit based on product, segment, account, and clinical specialty program needs and objectives)

  • Focus (ability to identify and manage to key, high-leverage information, tasks, and events)

  • Consistency (ability to facilitate staff adherence to identified workflows, plan requirements, clinical guidelines, to drive sound, objective decisions)

  • Negotiation (ability to resolve disputes and craft outcomes that address competing interests while achieving business objectives)

  • Call management (ability to structure staff workflows that drive telephone conversations that ensure value in every contact, achieve the desired objectives for placing the call, and are efficient and professional)

  • Clinical Management (ability to design workflows, identify processes, and facilitate consultative discussions that enable team members to conduct clinical assessment, clinical review, and management of an end to end episode of care)

  • Productivity (ability to prioritize and manage assigned workload to accomplish full slate of targeted activities)

  • Comfort and proficiency with the use of computers and technology (ability to navigate computer applications quickly and effectively, key in data proficiently in real time during phone calls, work effectively with the phone system, and quickly learn, and effectively work in, a variety of media)

Education/Relevant Experience:

  • Active Massachusetts RN License, required. Additional state licenses is a plus. Please Note: any restrictions and/or sanctions against a license must be disclosed and reviewed.

  • Minimum 3-5 years direct clinical experience working in either skilled nursing facilities, inpatient, sub-acute/rehab, LTAC, homecare, and/or outpatient rehab setting, preferred

  • Medical Policy experience, a plus

  • Bachelors' degree in nursing, preferred

  • 2 years supervisory experience, preferred

  • Ability to work in a highly computerized environment

  • Bilingual a plus

This job description is not intended to be all inclusive and this role may have additional responsibilities as assigned by leader.

LocationQuincyTime TypeFull time

Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power , Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

Our Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.