Utilization Management Operations Manager

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

Location: Primarily remote. May require occasional travel to local facilities including Tufts Medical Center, Melrose Wakefield Hospital, Lowell General Hospital, and our Corporate Headquarters in Burlington, MA.

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. 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. Bachelor's Degree

2.Five (5) years of experience in Health Care

3. Two (2) years of experience in a supervisory or management role

Preferred Qualifications:

EPIC Experience

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. Collects of patient demographics including payer information from referral sources

2. Oversees and collaborates with UR vendor.

3. Sets goals with individual team and as a group

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

5. Monitors vendor quality and production and provides feedback to vendor and CDI/UR Director.

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

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

8. Manages and oversees all work queues in EMR that apply to the Utilization Management department

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

10. Creates/changes file split according to the needs of the department

11. Reviews monthly write offs around denials for missing authorizations

12. Sets goals with individual team and as a group

Physical Requirements:

1. Normal office settings

Skills & Abilities:

1. Experience in Patient Access and Utilization Review roles

2. Excellent oral and written presentation skills

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.