RN Inpatient UM Manager, Inpatient Services at Tufts Health Plan in Watertown, Massachusetts

Job Description:

We enjoy the important work we do every day on behalf of our members.

Job Summary

The Inpatient Manager is a licensed professional that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of members across one or more types of inpatient settings; acute, subacute, acute rehabilitation, LTAC, CORF and others. The Inpatient Manager is responsible for making the determination of medical necessity and, therefore, benefit coverage for multiple products / lines of business; such as Commercial (FI, SI and exchange products), state specific Medicaid programs, or Federal programs or in and out of area (Carelink/Cigna).

The Inpatient Manager is expected to demonstrate the ability to work independently as well as collaboratively within a team environment. The Inpatient Manager will be expected to demonstrate sound clinical and health plan business knowledge in their decision making processes, on behalf of the health plan. A working understanding of departmental and corporate business objectives and accountability for outcome measures are critical to the Inpatient Manager's success in this role.

The Inpatient Manager provides timely, clinically appropriate and cost effective utilization management and discharge planning activities for THP members receiving services at her / his assigned facilities and may be required to float to provide coverage at unassigned facilities. Inpatient management II functions include but are not limited to; application of clinical relevant criteria sets in order to determine medical necessity, level of care and/or readiness for transition to a lesser level of care setting. The Inpatient Manager will develop effective working relationships with providers to facilitate the transition of the member through their continuum of care following department work processes and policies.

The Inpatient Manager will be expected to have direct experience with licensed clinical criteria sets (such as InterQual or MCG), THP proprietary Medical Necessity Guidelines and product specific payment policies. The Inpatient Manager may have responsibility for multiple types of service reimbursement models, depending upon the LOB and/or assigned facilities contractual arrangements. Examples include but may not be limited to DRG (APR and MS), case rate and/or per diem reimbursement models.

The Inpatient Manager works under the general direction of the Inpatient Team Manager or department Manager.

Job Description

Provide a range of utilization management activities for members in an inpatient setting.

• Utilize industry standard / plan proprietary criteria for determining the appropriateness of the inpatient setting on an initial and concurrent review basis, both acute and post-acute (as noted above).


• Determines reimbursement methodology and schedules concurrent review appropriately


• Reviews inpatient admissions, continued stays, telephonically or by other electronic means for length of stay (LOS), medical necessity, discharge planning and care coordination requirements / needs.


• Identifies and determines medical necessity of out of network requests for services


• Performs discharge planning for both acute and post-acute admissions.


• Identifies complex members and refers member to case management or disease management program based on member specific diagnoses, circumstances or psycho social needs, and product / LOB program requirements.


• May require telephonic and/or onsite presence at assigned facilities


• Redirects members and providers to in network or in network preferred providers, including transition back to the Tufts Health Plan service area.


• Identifies potential High Risk High Needs members and presents at case rounds for inclusion of additional interventions.


• Identifies potential high cost members for reserve or re-insurance planning.


• May be required to conducts preauthorization of transplant requests


• Performs case documentation according to Department standards including but not limited to timely completion of daily tasks, timely management of assigned UM events and same day case data entry


• Mentor new and existing staff in process and system changes/updates


• Facilitate UM/CM rounds


• Become subject matter expert (SME's) to support the Inpatient Management Initiatives including but not limited to Progeny, OON Management, MedHok, Medical Trend Management, Cigna Self Insured accounts etc.


• Assist the Team Manager in day to day activities/assignments to the team as needed.

Develop effective and collaborative relationships with key customers:

• With clinical and business staff of assigned facilities and physicians providing direct care to THP members in order to: actively participate in the assessment of the member's needs, matching the available in network provider and community services to those needs; recommend and facilitate adjustments to the care plan and services in place including the transition of OON admissions back into the network.


• With THP Medical Directors to determine ongoing coverage for inpatient services, including approved, denied and/or redirected services, ensuring that department business processes are followed or variances to the process are escalated, if needed, and agreed to and well documented


• With entities who support the UM function of the Carelink product, Cigna Travel


• With partner departments in / across THP to coordinate and expedite clinical and administrative processes as needed

Prepare cases for presentation at and actively participate in weekly UM/CM Integrated Rounds.

Participate in committees or as team liaison as needed.

Maintains professional growth and development through self-directed learning activities and/or involvement in professional, civic, and community organizations.

Performs additional related duties as assigned.

Requirements

EDUCATION: (Minimum education & certifications required)

• Registered Nurse with current, unrestricted MA license


• BSN: Preferred

EXPERIENCE: (Years of experience)

• Minimum of three years of clinical nursing experience.


• Minimum 3 years of UM experience, preferably in an inpatient setting or managed care environment

SKILL REQUIREMENTS: (Include interpersonal skills)

• Excellent interpersonal skills to form positive and collaborative relationships.


• Strong communication skills


• Excellent negotiation skills


• Ability to manage tasks to leverage non-clinical resources on team, provides quarterly audits of the non clinical denial letter team


• Use professional and clinical judgment to identify issues and escalate accordingly to a supervisor and relevant Tufts Health Plan departments


• Ability to apply nationally recognized standards to support utilization management


• Ability to mentor


• Ability to assume additional responsibilities such as special projects, while managing a case load


• Ability to use a laptop to accurately document utilization management activities adhering to department documentation standards


• Ability to work independently; highly motivated and self-directed with strong time management skills


• flexibility


• Proficiency with or ability to learn technology for initiating and participating in web/system based communications: webinar, instant messaging, thin client, soft phone or others


• Proficiency with or ability to learn technology based programs such as Microsoft Word and Excel; other programs as needed

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel,

Overtime)

• Fast paced business environment that requires the balancing of multiple demands.


• Must be able to exercise sound judgment and make evidence based clinical and business decisions


• Requires skill in responding to inquiries from providers as well as telephonic inquiries from internal and external customers.

CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.

What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!

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