Manager, Inpatient Management

The Manager of Inpatient Management 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 of Inpatient Management works collaboratively with appropriate Tufts Health Plan 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 THP 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 Tufts Health Plan business and quality goals. The Manager of Inpatient Management 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 Director, Inpatient Management.

KEY RESPONSIBIITIES

Accountable for development, implementation and effectiveness of new and existing Commercial and Public Plan medical management programs for inpatient utilization and discharge planning, including but not limited to:


* Commercial or Public Plan telephonic and onsite for utilization management across the inpatient level of care, including management of complex utilization cases in acute inpatient, LTAC, skilled nursing and rehabilitation facilities
* 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 Commercial or Public Plan Utilization Management and Transition of Care/discharge planning program processes, documentation standards and activities; including but not limited to 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 Commercial or Public Plans Inpatient Management to assure compliance with applicable state, federal, and regulatory and accrediting agencies; including maintaining timely audit /reporting cycles. Understands DOI, EEOHS, and NCQA 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 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





EDUCATION: (Minimum educations & certifications required)

BS degree in nursing required; Master's degree preferred (nursing, business, healthcare administration), or equivalent experience. Registered Nurse with current Massachusetts license required.

EXPERIENCE:

7 years of experience in managed care systems and operations.is required.

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 is required.



All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability or protected veteran status



Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled