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Director of Operations Utilization Management

WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294324)

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

TheDirector ofUtilization Management (UM) Operations isaccountablefordeveloping and maintaining the framework to achieve efficient and effective operational processes, policies and procedures to support the department’s performance and quality metrics. This includes responsibility for robust performance measurement monitoringand reporting for both clinical and non-clinical functions within UM and across all products to ensurespecifictargetsandgoalsrelatedtopeople,processanddata/technology are met.TheDirectorisalsoaccountableforthecontinuousassessmentofUMprogram operations,identifyingopportunities for improvement,assessingriskandcommunicatingobservations,recommendationsandresultstothe VP of UM.In conjunctions with the Director of Clinical UM, the incumbentis responsible for identifying ways to integrateUMfunctionsacross the organizationto create efficient workflows and handoffs as needed including integration with delegated vendors.

The Director leads and is accountable for the performance of a team of non-clinical staff including Prior Authorization, Inpatient UM specialists and Correspondence Coordinators.

Our Investment in You:

· Full-time remote work

· Competitive salaries

· Excellent benefits

Key Functions/Responsibilities:

Process

· Develops,implementsandevaluatesdepartmentalpolicies,processesandproceduresthatensureefficiency,effectiveness,qualityandconsistency and meet regulatory requirements.

· Developsandmonitorsperformanceandqualitymetrics, including audits and call monitoring. Notifies the VP of UM if performance falls below expectations, and works with leadership to develop a plan to improve performance.

· Leads and oversees the UM component of highly visible and complex initiatives (new software applications, upgrades, UM cost savings projects).

· Manages and ensures regulatory and accreditation UM standards for turnaround and documentation

· Ability to facilitate and implement new system implementation and upgrades including UAT and Quality testing.

· Analyzesmetricsandotherinformationtosubstantiateresults.

· Proactivelyidentifiesopportunitiestoimproveexistingprocessesoraddnewprocesses and recommends/proposes solutions to improve outcomes across the department. Anticipates downstream impacts of workflow/ process changes to UM department and other departments in the end to end process.

· Overseesthetimelyandaccurateproductionofregulatoryandcontractualreporting

· ActsasaliaisontoLegal,ComplianceandQualityDepartmentonissuesthathavebothlegalriskandcomplianceaspectsandcoordinateswiththeAccreditationManageronNCQA auditsaswellassupportingallcorrectiveactionsinassignedarea.

· AssiststheVPof UMindevelopmentand management ofthedepartmentbudget

· RepresentBMCHP/Well SenseUM operationsexternally as appropriatesuchasmeetingswithprovidergroupsandstateagencies.

· Attends various UM Committee meetings, as well as other departmental/organizational meetings

People

· Developsahighperformanceteamasevidencedby

o Meetingallprocessrequirements

o Elicitingtheteam’sparticipationinidentifyingopportunitiesforimprovement

o Meetingdefinedteamgoalssuchastargetedresultsofanannualteamsurvey

o Developing performance management skills in supervisory staff by modeling, managing, and setting clear expectations

· DevelopsandoverseesUtilization Managementstaff onboarding and ongoing role specific training, in conjunction with Clinical Manager of Utilization Management and OCA Trainer.

· Overseesthedevelopmentandexecutionofindividualprofessionaldevelopmentplansforalldirect reports consistent with the corporate performance management program.

Data/Technology

· Overseestheconsistentuseofsupporttechnologies

· Develops reporting with Analyst by thoroughly understanding needs, purpose and requirements

· Developsdepartmentaltargets,measuresandmetricsandintegratestheirmeaningfuluseacrossalldepartmentfunctionsandteammembers

· Continuouslyevaluatestoolsandtechnologiestoidentifynewopportunitiesforefficiencyoreffectiveness across all staff in the department

· Works with other business areas including IT, Clinical Informatics, and Quality as related to business requirement development , clinical management software configuration, and UA

Supervision Exercised:

· Directly manages 2-5 staff and indirectly manages 40-45 FTEs.

Supervision Received:

· Generalsupervisionisreceivedweekly from VP of UM.

E duc a tio n :

· Master’s Degree in Healthcare or related field preferred

E xp e r ien c e:

· 7 or moreyears of management operations experience

· 3 or moreyearsofexperiencewithMedicaid/Medicare Managed Care or other health plan experience

Pr ef e r r ed/D e si r able:

· Healthcaresystemsexperience

· Healthplanorinsuranceenvironmentexperience

· Vendor experience

· Experience in an operations environment with regulatory turnaround times.

· Experiencemanaging cross functional projects.

Ce r tific a tion o r Conditio n s of E m p l o y m en t :

· Pre-employmentbackgroundcheck

Com p etenci e s, S ki l l s, a n d A tt r ib u t e s:

· Experiencemanagingcomplexprocesses

· Attention to detail

· Ability tomeetaggressivetimelineswhenrequired

· Abilitytodevelopahighfunctioningteam

· Experiencewithdatadrivendecisionmaking

· Knowledgeofmetrics,andanabilitytocompile,format,interpret,andpresentdata

· Masteryofverbalandwrittencommunicationskills,including but not limited to the ability totranslatecomplexsubjectmatterintounderstandableinformationtailoredtospecificaudiences

· Abilitytosuccessfullyplan,organize,implementandmanageprojectswithinahealthcaresetting.

· StrongworkingknowledgeofMicrosoftOfficeapplications

· Aptitude for matching business requirements to potential software solutions

· Stronganalyticalandproblemsolvingskills.

· Knowledgeofprocessimprovementtechniques.

W o r king Conditio n s a nd P h y s i c a l E ffo r t:

· Regularandreliableattendanceisanessentialfunctionoftheposition.

· Workisnormallyperformedinatypicalinterior/officeworkenvironment.

· Noorverylimitedphysicaleffortrequired.Noorverylimitedexposuretophysicalrisk.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294324)

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