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Director, Utilization Mgmt & Member Services - MA LTSS (Boston)

UnitedHealth Group

Boston, MA
Job Code:
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Director, Utilization Mgmt & Member Services - MA LTSS (Boston)(Job Number:702867)

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)
The Director, Utilization Management and Member Services is a lead position and is accountable for employees that perform utilization management and member services. 
Primary Responsibilities:
  • Establish leadership, structure, policies and procedures, monitoring and oversight processes to ensure overall outcomes and optimal UM program performance
  • Oversight of  Intake and Member Services ensuring timely call response time, issue resolution and properly escalated concerns or operational issues
  • Ensure needs based member service plans within established plan thresholds and guidelines
  • Oversee the UM daily operations and weekly clinical rounds
  • Conduct prior authorization Secondary Reviews to confirm that the LTSS service plan meets the member’s needs and that LTSS services are allocated appropriately
  • Conduct  peer to peer consultations as appropriate
  • Coordinates monthly and annual reporting to EOHHS inclusive of all prior authorization requests upon request
  • Training of internal utilization management and member services staff
  • Assist with LTSS provider communications and process education
  • Process inter-rater reliability study results providing feedback at the individual level
  • Examine utilization, cost, and quality measures across LTSS services, differences across providers and regions, and service utilization consistency with member clinical and functional assessment data
  • Have a deep understanding of the Massachusetts LTSS delivery system, including EOHHS waiver and home care programs, EOHHS contracted clinical assessment organizations and case management entities
  • Provide a monthly PA and UM Activity report with recommendations for improvements and associated cost impact assessment for EOHHS approval
  • Work actively with LTSS providers to develop or access additional capabilities that can help members thrive in a more independent setting and collaborate with PCM agencies and case management entities to ensure members get the support that they need to safely remain in the community
  • Validate and review MMQ audits with reporting of results
  • Analyze the rate and reasons of prior authorization modifications, denials, appeals, and overturns by provider type
  • Actively participate in the Quality Improvement Committee and LTSS Provider Quality Forum to identify improvement opportunities promptly and address them
  • Oversight of Appeals process and Appeals Coordinator
  • Support continuous improvement of annual employee engagement scores
  • Provides coverage for RN Provider Relations Lead and Appeals Coordinator

Job Clinical Utilization Managemen
Primary Location US-MA-Boston
Other Location 
Organization Government Solutions Sr Mgmt
Schedule Full-time
Number of Openings 1
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UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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