Manager, Medicare Advantage Coordinated Care
Mass General Brigham Health Plan, Somerville, MA, United States
Responsibilities
Oversee daily operations of care coordination and case management teams, including registered nurses, social workers, and support staff.
Ensure timely and effective coordination of patient care plans, including discharge planning, transition of care, and resource referrals.
Monitor workflows to support appropriate utilization review, medical necessity determinations, and regulatory compliance.
Collaborate with clinical leadership, physicians, and external providers to resolve barriers to care and optimize patient flow.
Develop and maintain policies, procedures, and workflows that align with industry standards, payer requirements, and internal goals.
Manage performance metrics, including readmission rates, length of stay, denial rates, and patient satisfaction outcomes.
Facilitate staff education, training, and professional development, support certification in case management and care transitions.
Represent care coordination in interdisciplinary committees, quality improvement initiatives, and accreditation readiness efforts.
Ensure compliance with CMS, Joint Commission, and other applicable regulations and standards.
Education
Bachelor's Degree required
Master's Degree preferred
Licenses and Credentials
Massachusetts Registered Nurse (RN) required
Experience
At least 5-7 years of experience in care coordination, case management, or discharge planning in a healthcare setting required
At least 2-3 years of experience in a supervisory or leadership required
At least 1-2 years of experience with utilization review, value-based care, population health, managed care principles, transitional care models, and interdisciplinary care planning preferred
Experience working for a health plan supporting its Medicare Advantage line of business highly preferred
Experience preparing for CMS audits highly preferred
Knowledge, Skills, and Abilities
In-depth knowledge of case management standards, patient care coordination strategies, and healthcare regulations.
Strong leadership, team-building, and staff development skills.
Excellent communication, problem-solving, and negotiation abilities.
Ability to analyze data, identify trends, and implement process improvements.
Proficiency in electronic health records (EHRs), case management systems, and reporting tools.
Working Conditions
This is a hybrid role with occasional office visits (a few times per quarter)
Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
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Oversee daily operations of care coordination and case management teams, including registered nurses, social workers, and support staff.
Ensure timely and effective coordination of patient care plans, including discharge planning, transition of care, and resource referrals.
Monitor workflows to support appropriate utilization review, medical necessity determinations, and regulatory compliance.
Collaborate with clinical leadership, physicians, and external providers to resolve barriers to care and optimize patient flow.
Develop and maintain policies, procedures, and workflows that align with industry standards, payer requirements, and internal goals.
Manage performance metrics, including readmission rates, length of stay, denial rates, and patient satisfaction outcomes.
Facilitate staff education, training, and professional development, support certification in case management and care transitions.
Represent care coordination in interdisciplinary committees, quality improvement initiatives, and accreditation readiness efforts.
Ensure compliance with CMS, Joint Commission, and other applicable regulations and standards.
Education
Bachelor's Degree required
Master's Degree preferred
Licenses and Credentials
Massachusetts Registered Nurse (RN) required
Experience
At least 5-7 years of experience in care coordination, case management, or discharge planning in a healthcare setting required
At least 2-3 years of experience in a supervisory or leadership required
At least 1-2 years of experience with utilization review, value-based care, population health, managed care principles, transitional care models, and interdisciplinary care planning preferred
Experience working for a health plan supporting its Medicare Advantage line of business highly preferred
Experience preparing for CMS audits highly preferred
Knowledge, Skills, and Abilities
In-depth knowledge of case management standards, patient care coordination strategies, and healthcare regulations.
Strong leadership, team-building, and staff development skills.
Excellent communication, problem-solving, and negotiation abilities.
Ability to analyze data, identify trends, and implement process improvements.
Proficiency in electronic health records (EHRs), case management systems, and reporting tools.
Working Conditions
This is a hybrid role with occasional office visits (a few times per quarter)
Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
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