Manager, Utilization Management

**Why This Role is Important to Us:**Commonwealth Care Alliances (CCA) Clinical Effectiveness (Authorization) Unit is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services,procedures, and facilities under the provisions of CCAs benefits plan.The Manager, Utilization Management is responsible for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff responsible for conducting centralized clinical review and authorization creation for centrally-authorized services. This position has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations.The Manager, Utilization Management reports to the Director of Clinical Effectiveness.**What You'll Be Doing:**+ Oversees clinical decision review for services requiring prior authorization in a variety of clinical areas,+ including but not limited to surgical procedures, Medicare Part B medications, long term services and supports (LTSS), and home health (HH).+ Maintains and optimizes Standard Operating Procedures related to authorization review+ Ensures timely and accurate communications of medical necessity review results to the original requester (e.g., primary care team, specialty providers, vendors) in compliance with regulatory and contractual requirements+ Manages the process for escalated reviews in accordance with Standard Operating Procedures.+ Provides guidance to UM Nurses and clinical teams as needed+ Liaises with clinical teams and re-insurer on high cost cases Ensures that department and organizational policies and procedures as well as regulatory and contractual+ requirements and other regulatory reporting needs are met.+ Tracks and monitors teams performance against targets; identifies,+ recommends, and implements opportunities for improvement as needed+ Investigates and resolves member complaints and grievances related to relevant services and supports;+ conducts audits and performs quality assurance**What We're Looking For:**+ Associate's Degree in Nursing, Bachelor's Degree preferred+ Registered Nurse licensed in the Commonwealth of Massachusetts in good standing.+ 3-5 years utilization management experience required+ 3+ years experience working in a health plan, specifically with utilization management required+ 3+ years of management experience preferred+ Will be required to pass CCAs credentialing process.+ Demonstrated ability to establish and manage performance and outcome metrics.+ Excellent collaboration and communication skills with the ability to partner effectively across the organization and with external partners.+ Familiarity with Interqual criteria applied to procedures+ Flexibility and understanding of individualized care plans+ Strong strategic thinker and tactical performer+ Strong project management skills with the demonstrated ability to handle multiple projects.+ Ability to establish and maintain positive and effective work relationships with internal staff, external vendors,and state and federal agencies+ Proven skills and judgment necessary for independent decision-making.+ Excellent organizational, time-management and problem-solving skills+ Strong management skills+ Ability to influence decision making+ English required, bilingual preferred.EEO is The LawEqual Opportunity Employer Minorities/Women/Protected Veterans/DisabledPlease note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.