Manager of Utilization Management
Baystate Health’s Health New England is seeking a Manager of Utilization Management to lead our Utilization Management Health Services Team and help shape the delivery of high-quality, cost-effective, member-centered care in Springfield, MA. Responsibilities: - Lead and Inspire a Clinical Team - Manage, mentor, and develop registered nurses and non-licensed clinical support staff. - Monitor team performance, establish expectations, and provide coaching, training, and continuing education. - Identify operational challenges and implement corrective action plans and performance improvements. - Promote consistent processes, accountability, and professional development across the department. - Drive Clinical Quality and Operational Excellence - Oversee utilization management processes across Commercial, Medicare, and Medicaid lines of business. - Partner with the Medical Director to develop Quality Improvement Activities and oversee Delegation Agreements. - Evaluate clinical treatment criteria and ensure staff are appropriately trained in their application. - Use data to measure outcomes, identify trends, monitor performance, and recommend opportunities for improvement. - Develop and implement processes that support positive member outcomes and responsible healthcare cost management. - Monitor compliance with NCQA, MCRA, and other applicable regulatory requirements. - Build Strategic Partnerships - Serve as the relationship manager for assigned vendors, providing oversight and supporting effective partnerships. - Collaborate with Provider Relations, Healthcare Economics, Sales, Member Services, Claims, ASO, and other internal teams. - Support project and product implementations and assist in evaluating new technologies and applications. - Maintain the Health Services Operations Manual in partnership with department leadership. - Present updates, findings, and recommendations to executive leadership, management, and peers. - Lead department participation in the Manager-Led Problem Solving process. Location and