System Director Utilization Management - Primarily Remote

Utilization Management Coordinator

Hours : Full-time, Monday through Friday. May require additional hours on weekends / off hours as needed.

Location : Primarily remote. May require occasional travel to local facilities including Tufts Medical Center, Melrose Wakefield Hospital, Lowell General Hospital, and our Corporate Headquarters in Burlington, MA.

About Tufts Medicine : Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. The health system is the principal teaching affiliate for Tufts University School of Medicine. The strong relationship between Tufts Medicine and Tufts University School of Medicine is evident in our governance, academic and research structure. Tufts Medicine is comprised of the following clinical entities :

• Tufts Medicine Professional Group (TMPG)
• Tufts Medicine Integrated Network (TMIN)
• Tufts Medical Center
• Lowell General Hospital
• MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford
• Tufts Care at Home

Job Overview : The position coordinates the design, development, implementation, and monitoring of the organization's utilization review functions. The position establishes the department's strategy and vision and oversees daily UM operations. The position functions as the internal resource on issues related to the utilization of resources, coordination of care across the continuum and utilization review and management. The position develops and leads the Utilization Management operations, strategy and implementation of the Utilization Management model and tactics. The position is responsible for assuring success in financial management, human resources management, leadership, quality and operational management objectives. The position consistently demonstrates the core values of Tufts Medicine and serves as a role model for other employees.

Job Description : Minimum Qualifications : 1. Bachelor of Science in Nursing (BSN). 2. Massachusetts RN Licensure. 3. Current certification in case / utilization management (ACM, CCM, CMAC) 4. Seven (7) years of UM / Case Management experience in an acute-care hospital or multi-hospital system, including two (2) years of supervisory experience.

Preferred Qualifications : 1. Master's in Nursing 2. Fluent in CMS Two-Midnight, Inpatient-Only, Condition Codes 44 & W2, MOON / IMM, and payer-specific admission guidelines

Duties and Responsibilities : The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

Physical Requirements : Normal office settings

Skills & Abilities : Knowledge of InterQual and MCG medical-necessity criteria Experience with Lean / Six Sigma or similar methodology to redesign and improve workflows Proven ability to run multi-disciplinary projects Confident presenter to executives, physician committees, and payer medical directors Skilled at writing clear policies, job aids, and appeal letters Ability to manage conflict between clinical teams and finance / rev cycle priorities

Job Profile Summary : This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, this role focuses on performing the following Patient Access duties : Performs the administrative and financial-clearance duties necessary to facilitate the procurement of clinical services by patients. Collects patient's necessary demographic and financial information from physician offices, acute-care entities, or the patients themselves, schedules services for patients, and handles referrals from primary care doctors to ensure patients are scheduled for recommended appointments / procedures, etc. A management role that supervises employees focusing on tactical, operational activities within a specified area, with the majority of time spent overseeing area of responsibility, planning, prioritizing and / or directing the responsibilities of employees. Goal achievement is typically accomplished through performance of direct and / or indirect reports. A role that directs a department or small unit that includes multiple teams led by managers and / or team Leaders. Responsibilities typically include : ownership of short to mid-term (1-3 years) execution of functional strategy and the operational direction of the Department, problems faced are often complex and require extensive investigation and analysis, and requires ability to influence others to accept practices and approaches, and ability to communicate and influence executive leadership.