Senior Manager Medical Expense Management

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Responsible for coordinating care management activities and clinical program development.  Provides coordination of the overall activities of care management department.  Leads the development of care management objectives, policies, plans, programs and budgets while maintaining a cost efficient and effective service, supporting the organization's clinical practices.

Primary Responsibilities:

• Oversees Utilization and Referral programs, including acute care, skilled nursing facility and home care, achieving targeted outcomes
• Integrates utilization and referral management groups.  Organizes to maximize program efficiency and effectiveness.  Recruits and oversees team leaders.  Oversees evaluation of the clinical performance of the department and staff.  Oversees the day-to-day operations of all utilization and referral management programs
• Manages identification of pending high cost cases
• Responsible for compliance to and meeting all NCQA requirements for delegated case management as well as being responsible for NCQA certification for utilization management
• Responsible for the successful implementation of all future, delegation efforts
• Manages expenditures such as utilization: inpatient, SNF, hospital outpatient expenses: ER, facility, home care, ambulance, DME, tertiary referrals and POM with Service Director, regional leadership and others, participate in clinical program development, implementation, business plans, trade-off proposals
• Manages inpatient and outpatient populations to anticipate needs, optimize outcomes and cost-effective care.  Implements and monitors programs focused on proactive outreach for high-risk patients
• Ensures quality of department services via ongoing training of staff, case review, internal audits and inter-rater reliability audits
• Interfaces and resolves issues with vendors such home health care, hospitals, nursing facilities, etc., to ensure appropriate quality of care and service is delivered to patients.  Participates in research activities to establish benchmarks; stay informed about innovative programs that can be replicated at the organization
• Recruits and selects members of the utilization and referral management teams to manage the needs of assigned areas of responsibility
• Delegates authority and responsibility to members of the teams for the operation and coordination of the programs and services
• Works with department leaders to minimize outside referrals and resolve identified barriers to care
• Acts as a resource for team members as needed
• Manages the business and fiscal affairs of the department, including the preparation of business plans and annual capital and operating funds budgets.  Monitor and assume corrective action for variances
• Establishes positive working relationships with the organization's site staff as well as payer staffs and management
• Directs and supervises assigned personnel including performance evaluations, scheduling, orientation, and training.  Makes recommendations on employee hire, transfers, promotions, salary changes, discipline, terminations, and other similar actions.  Resolves grievances and other personnel problems within position responsibilities
• Develops and recommends, in conjunction with manager, the operating and capital budgets for the areas managed.  Manages activities to assure financial goals met.  Monitors expenditures for compliance to approved budget.  Resolves discrepancies
• Coordinates the assignment of tasks and helps resolve technical and operational problems.  Evaluates the impact of solutions to ensure goals are achieved
• Provides effective direction, guidance, and leadership over the staff for effective teamwork and motivation, and fosters the effective integration of efforts with clinic-wide initiatives
• Participates in performance improvement initiatives and recommends procedural changes when appropriate
• Ensures compliance with regulatory agencies such as DPH, etc.  Develops and maintains procedures necessary to meet regulatory requirement
• Ensures that assigned area comply with clinic established policies, quality assurance programs, safety, and infection control policies and procedures
• Ensures adequate equipment and supplies for assigned area
• Ensures compliance to all health and safety regulations and requirements
• Performs similar or related duties as required or directed
• Regular, reliable and predicable attendance is required

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. 

Required Qualifications:

• BSN
• Current Massachusetts RN licensure
• 5+ years of relevant experience
• Proven experience in coordination and management of treatment services
• Demonstrated leadership ability in building teams which have worked to achieve a common goal
• Knowledge of budget development and management, and collaborative multi-specialty program development and management
• Knowledge of Utilization Management and Case Management
• Excellent organizational, communication, and interpersonal skills
• Knowledge of a variety software products such Microsoft Outlook, Word, Excel, PowerPoint, etc.
• Driver's license and access to reliable transportation

Physical Requirements:

• Physical health sufficient to meet the ergonomic standards and demands of the position
  

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $91,700 - $163,700 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.    

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.  

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.