Manager Utillization Management Operations

Hours: Full-time, Monday through Friday. May require additional hours on weekends/off hours as needed.

Job Profile Summary

This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, this role focuses on performing the following Utilization duties: Ensures the delivery of clinical services is appropriate and efficient. Completes clinical admission review of admission on all observation and inpatients, using industry-standard medical necessity guidelines and submits supportive clinical documentation to patient's health insurers to ensure authorization for clinical services, etc. A management role that supervises employees focusing on tactical, operational activities within a specified area, with the majority of time spent overseeing area of responsibility, planning, prioritizing and/or directing the responsibilities of employees. Goal achievement is typically accomplished through performance of direct and/or indirect reports. A role that manages experienced professionals who exercise latitude and independence in assignments. Responsibilities typically include: policy and strategy implementation for short-term results (1 year or less), problems faced are difficult to moderately complex, and influences others outside of own job area regarding policies, practices and procedures.

Job Overview

The position provides day to day support and oversight to Utilization Review departments and UM vendor management. The UM Operations Manager is responsible for compliance with CMS Conditions of Participation regarding Utilization Review and Discharge Planning including implementation and annual review of the Utilization Management Plan and assisting with the coordination of the Utilization Management Committee. The Utilization Management Operations Manager follows the system's Utilization Program that integrates the functions of utilization review and resource management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated resources. The system's utilization management model outlines a collaborative practice to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes.

Job Description

Minimum Qualifications:

1. Registered Nurse (BSN or higher) or other licensed clinical professional (PharmD, PA, MD/DO)

2. Current certification in case/utilization management (ACM, CCM, CMAC)

3. Five (5) years of progressive UM/Case Management leadership in an acute-care hospital or multi-hospital system

4. Fluent in CMS Two-Midnight, Inpatient-Only, Condition Codes 44 & W2, MOON/IMM, and payer-specific admission guidelines

Preferred Qualifications:

1. Master's in Nursing, Healthcare Administration, or Business (MSN/MHA/MBA

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Regulatory & Payer Relations: Navigates Medicare, Medicare Advantage, Medicaid, and commercial payer rules. Tracks record of overturning medical necessity denials and driving appeal win rates. Translates regulatory changes into operational workflows.

2. Vendor & Stakeholder Management: Serves as day-to-day manager between outsourced UM vendor teams and internal physicians, nursing leadership, revenue cycle, CDI, finance, and IT. Negotiates SLAs, monitors vendor KPIs, and resolves performance gaps.

3. Data, Analytics, & Reporting: Strong command of denial analytics, observation vs. inpatient metrics, avoidable day analysis, and LOS optimization. Hands-on ability with Power BI, Epic reporting workbench, or similar tools to build dashboards and tell a story with data.

4. Oversees, validates, and directs the daily assignment of employees within the work group.

5. Ensures policies, practices and procedures are understood and followed by direct reports and vendor.

6. Provides training and education on an as needed basis based on when changes are made or identified during audits.

7. Responsible for hiring and providing work directions, and assignments which may include training within the department.

8. Sets goals with individual team and as a group.

Physical Requirements:

1. Normal office settings

Skills & Abilities:

1. Knowledge of InterQual and MCG medical-necessity criteria

2. Experience with Lean/Six Sigma or similar methodology to redesign and improve workflows

3. Proven ability to run multi-disciplinary projects

4. Confident presenter to executives, physician committees, and payer medical directors

5. Skilled at writing clear policies, job aids, and appeal letters

6. Ability to manage conflict between clinical teams and finance/rev cycle priorities

Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at careers@tuftsmedicine.org.