Manager, Behavioral Health Utilization Management

Under the oversight of the Director, Behavioral Health, the Manager, Behavioral Health Utilization Management (BH UM) is responsible for leading the Government Plans Inpatient BH UM team, which includes Medicare, Duals and Medicaid lines of business. The manager is responsible for compliance oversight, management of team performance and results, and for managing the clinical processes that support the Behavioral Health department. The Manager, Behavioral Health UM is a member of the BH UM leadership team; in addition to their own responsibilities the Manager assists in supporting and covering for other Behavioral Health leaders and participates in a variety of cross-functional Behavioral Health initiatives and processes.

The Manager, in collaboration with the Director, is responsible for the development, implementation and maintenance of Behavioral Health initiatives and projects, as well as achievement of goals consistent with federal, state, and national requirements and regulations, and specific Tufts Health Plan initiatives and goals. The position is responsible for representing the Behavioral Health department on relevant internal and external work groups, implementation teams, and projects, for interfacing with divisional and enterprise teams, and for managing Behavioral Health accreditation compliance.

• Manage daily operations including, but not limited to, the assignment and distribution of work among assigned BH UM team(s). Ensure all UM activities are completed within the required timeframes and other compliance requirements, and telephone coverage requirements are met. Ensure adherence to all department and regulatory standards.
• Under the direction of the Director of Behavioral Health, develop, implement and manage initiatives and projects to achieve Tufts Health Public Plans goals. Collaborate with internal departments in support of clinical activities and operations.
• Work collaboratively on and manage components of quality improvement initiatives and medical expense reduction activities and ensure alignment with broader company strategy. This includes activities that support CMS and NCQA accreditation and identify and promote best practices within clinical programs.
• Provide monthly Care Management report on team(s) performance, metrics, and goal achievement to the Director of Behavioral Health.
• Complete monthly clinician case review audits and review semi-annual IRR results to monitor UM decision making and adherence to policies and procedures. Identify trends, develop and implement action plans for improvement progress
• Develop and prepare reports to meet internal, regulatory, contractual and accreditation requirements. Work closely with other departments in the development of report specifications and obtain data for and/or complete reports as needed to meet contract and regulatory requirements and track ongoing data.
• Serve as member of BH UM leadership team. Provide back-up for peers, including supervisory coverage. Partner with peers to ensure effective cross-functional, end to end approach to meet the needs of members, providers, and internal and external stakeholders.
• Support and help drive efforts to integrate Behavioral Health into the broader Tufts Health landscape by providing a cohesive behavioral health presence and subject matter expertise to Public Plans and Enterprise activities including case management, medical management, and provider/network management.
• Hire, train, and manage staff. Supervise/coach staff to assist them in attaining optimal knowledge and job efficiency. Define metrics and goals for assigned team(s) and manage expectations. Utilize data to monitor and evaluate individual, team and program performance. Provide timely feedback to all staff regarding their performance via regular team and one-on-one meetings. Conduct formal performance appraisals. Take appropriate disciplinary action in a timely manner when needed. Ensure staff is provided with all necessary tools, resources and training to promote growth and performance within the department and/or organization.
• Review and develop department policies, procedures, workflows and job aids as needed, consistent with departmental and company strategic objectives and mission. Develop, maintain, update orientation materials in collaboration with clinical trainer.
• Provide information and support to internal stakeholders. Work collaboratively with other managed care entities, MassHealth, the Executive Office of Health & Human Services, as well as provider and other stakeholder groups.
• Other duties and projects as assigned.
• Monitor utilization management and ensure servicing goals are met or exceeded by tracking department metrics. Apply data, utilize evidence-based treatment practices and identify opportunities for improvement of quality of care and medical expense savings to design, implement and enhance utilization management and clinical care coordination processes. Track and monitor the impact of utilization management and care coordination on quality and medical expense measures.

• Active unrestricted Massachusetts licensure to practice independently as behavioral health clinician (LICSW, LMHC, LMFT, RN, PHD, PsyD)
• Master’s degree in behavioral health related discipline (social work, counseling psychology or related field, nursing)

• 5-8 years post-master’s direct clinical experience, including utilization management in behavioral health or managed care
• Experience with Medicare and Medicaid
• 5-8 years of supervisory experience preferred

• Able to set priorities and deliver results even when turnaround time is short, or resources are limited. Able to balance clinical, operational, and business needs.
• Able to lead and work effectively within cross-functional teams.
• Able to create efficient workflows that maximize resources.
• Demonstrated understanding and proficiency in the principles, concepts and techniques of managed care and utilization management.
• Able to respond effectively to internal and external stakeholders, including customers and regulators and including delivery of presentations, response to complaints, involvement in sales, and participation in site visits and audits.
• Able to manage ambiguity and change, and lead a team’s effective management of shifting priorities, competing demands, and rapidly changing conditions.
• Able to secure the engagement of staff at a variety of levels and manage performance in a production environment.
• Able to use independent judgment and discretion in making decisions which may impact the organization.
• Able to build relationships with stakeholders at a variety of levels and communicate effectively verbally, non-verbally and electronically.
• Able to effectively supervise a workforce of both physically present and remote staff. Able to effectively manage end-to-end clinical and business processes.

• May be required to work additional hours beyond standard work schedule.
• Work from home, with occasional travel to Canton, MA office as needed.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.