Manager, Inpatient

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. 

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

The Manager, Inpatient manages Utilitzation Management (UM) Clinicians in day to day operations of the UM Process and is responsible for medical management activities related to utilization and discharge planning for acute inpatient, LTAC, rehabilitation and skilled nursing as well as Out of Network Management. S/he is accountable for implementation, monitoring and oversight of department functions and programs and the delivery of defined metrics to validate business unit/program effectiveness. The Manager, Inpatient works collaboratively with appropriate Point32Health departments and staff to identify and address opportunities to improve service, reduce administrative cost and demonstrate outcomes for functions and programs within jurisdiction. The Manager must have working knowledge of all Point32Health product lines to provider cross coverage for other Clinical Services Inpatient Managers. The Manager works collaboratively with the divisional case management departments, contracted provider and employers to address opportunities to improve service to and optimize the business relationships, while meeting the Point32Health business and quality goals. The Manager, Inpatient partner’s to support the delivery of services through integrated care teams to support an optimal wellness and care experience for the individual member. The Manager is accountable for recruitment, evaluation, management and development of Team Managers within jurisdiction. This position reports to the Senior Manager, Inpatient UM.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

Business Process Implementation and Oversight

• Accountable for development, implementation, and effectiveness of new and existing Commercial , Public Plans & Senior Products medical management programs for inpatient utilization and discharge planning, including but not limited to:
  • Development and implementation of operational measures and reporting for functions within business unit in collaboration with clinical services informatics
  • Collaborative interface with case management program leaders, supporting transition of care needs, complex discharge planning and high-risk members.
  • Collaborate with department and training resources to ensure development and maintenance of an evidenced based training program
  • Establishment of written policies and procedures pertaining to lines of business.
  • Conducts medical rounds, interfaces with Medical Director and CMOs, and partner departments such as Appeals and Grievances, Behavioral Health, Contracting / Provider Relations, Customer and Provider Services, Claims, Quality, and Precertification Operations departments.
  • Establish written policies and procedures pertaining to all lines of business.
  • Inpatient Management to assure compliance with applicable state, federal, and regulatory and accrediting agencies, including maintaining timely audit /reporting cycles. Understands DOI (Department of Insurance), EEOHS (Executive Office of Health and Human Services), and NCQA (National Committee for Quality Assurance) & CMS (Center of Medicare Services) requirements.
  • Ensure compliance with applicable contractual service agreements with network, vendor, and employer business partners.
  • Oversees the identification of high-risk/high-cost complex members for appropriate program case management through proactive concurrent review process.
  • Manages the function of analyzing metric driven data to determine the impact of plan policies and benefits upon the Plan, Providers, membership, and groups
  • May assist Director with staffing ratios and budget requirements for department as needed.
  • Develop, review, revise and monitor workflows and procedures to ensure that all work of the medical inpatient management team meets all compliance, regulatory and accrediting standards for NCQA, DOI and EOHHS (Executive Office of Health and Human Services) while integrating product specific management programs. Ensures consistent use of review guidelines and medical necessity guidelines.
  • Serve as a consultant and resource to Team Manager and staff for complex situations that arise around regulatory issues.
  • Demonstrates the leadership and business acumen to support Medicaid products for additional growth in other states

Staff Development

• Provide direct oversight of Team Managers within jurisdiction.
• Guides and enhances the professional development of the team manager and staff. Provides coaching, feedback, and direction thru a development plan to ensure successful achievement of business and professional goals Assists Team Manager with coaching and mentoring skills as needed
• Guide and enhance the professional development of reporting staff.
• Collaborate on development and ensure maintenance of an evidenced based training program
• Serve as consultant and resource for complex situations.

Resource Management

• Support budget process and oversee the management of department resources.
• Accountable for realization of department administrative budget targets.

Corporate Participation

• Represent Clinical Services / Inpatient Management in relevant corporate teams as required.
• Implement and support fulfillment of corporate goals through defined, measurable department goals.
• Enhance employee engagement through defined initiatives and resources.
• Participate in corporate initiatives and projects within jurisdiction.
• Other projects and duties as assigned.

Qualifications – what you need to perform the job

Certification and Licensure

• Registered Nurse with current Massachusetts license preferred.

Education

• Required (minimum): BS degree in nursing
• Preferred: Master’s degree (nursing, business, healthcare administration), or equivalent experience.

Experience

• Required (minimum): 5 years’ Registered Nurse, Leadership experience in managed care systems and operations. Demonstrate sound knowledge of utilization management and case management principles. Experience will demonstrate a functional knowledge of utilization management within a variety of payment models. Expertise in business process changes and leading people.
• Preferred:

Skill Requirements

• Ability to work cooperatively as a team member across multiple levels within the organization
• Results orientation to meet business goals
• Critical and Analytic thinking – must understand cause and effect, internal and external impact of business changes and Point32Health information systems
• Influencing others – particularly those outside of direct reporting relationships
• Strong communications skills (formal and informal, written and verbal)
• Coaching and Mentoring - primarily of reports, but also of others
• Must have commitment to excellence in customer service
• Considers creative alternatives to traditional/conventional practices and takes risk when appropriate to the situation.
• Regard for confidential data and adherence to corporate compliance policy
• Ability to handle multiple demands--must be able to balance multiple priorities
• Initiative, sound judgment, and the ability to work under pressure in a constantly changing environment balancing multiple priorities and utilizing resources aggressively.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.
• Travel required as needed. Occasional evening, weekend, early morning, or extended day work may be required.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

$101,216.82 -$151,825.24

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization.  The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage

• Retirement plans

• Paid time off

• Employer-paid life and disability insurance with additional buy-up coverage options

• Tuition program

• Well-being benefits

• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

We welcome all
All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org