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Utilization Management Care Manager

Company: Partners Healthcare System
Location: Somerville
Posted on: June 6, 2021

Job Description:

Summary of Position

A career at AllWays Health Partners is you in every way! Inspired by our affiliation with Partners HealthCare, our promise as a people-first organization starts with our employees. Get inspired to bring your unique talents to our diverse community and challenge the health care industry status quo with innovative programs that put people first. Our perks include a competitive benefits package, access to world-class doctors, and more.

The UMCM will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review as well as complete determinations following physician review.

Essential Functions

  • Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within AllWays Health Partners as needed.
  • Manage incoming requests for procedures and services including patient medical records and related clinical information.
  • Adherence to program, departmental and organizational performance metrics including productivity.
  • Excellent communication skills both verbal and written; excellent problem solving and customer service skills are required.
  • Must be self directed and highly motivated with an ability to multi-task.
  • Develop and maintain effective working relationships with internal and external customers
  • Hold self and others accountable to meet commitments.
  • Ensure diversity, equity, and inclusion are integrated as a guiding principle.
  • Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
  • Build strong relationships and infrastructures that designate AllWays Health Partners as a people-first organization.

Department Specific Functions

  • Experience with clinical applications/systems.
  • Proficiency in PC operating system, MS Office applications
  • Other duties as assigned with or without accommodation.

Working Conditions and Physical Effort

  • Work is normally performed in a typical office work environment.

Knowledge and Education

Required:

  • Registered Nurse (RN) with current state license, plus BSN or equivalent experience.

Preferred/Desired:

  • UM Certification (InterQual)

Experience

Required:

  • 3-5 years of experience.

Preferred/Desired:

  • 1-2 years experience in a payer setting
  • Experience using InterQual/Milliman

Skills/Competencies

  • Demonstrate AllWays Health Partners' core brand principles of always listening, challenging conventions, and providing value.
  • Strong aptitude for technology-based solutions.
  • Ability to inject energy, when and where it's needed.
  • Respect the talent and unique contribution of every individual, and treat all people in a fair and equitable manner.
  • Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
  • Be accountable for delivering high-quality work. Act with a clear sense of ownership.
  • Bring fresh ideas forward by actively listening to and working with employees and the people we serve.

Organizational Relationships/Scope

The UM CM reports directly to the assigned UM department supervisor

Keywords: Partners Healthcare System, Somerville , Utilization Management Care Manager, Other , Somerville, Massachusetts

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