- RQ4059031
Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Job Summary
Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.
Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.
We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.
The role is an integral part of our clinical coordination team, providing support to providers, facilities, and members to ensure a streamlined and timely transition from one level of care to another. This position will serve as the single point of contact for facilities and providers when a member requires specialized support, when complex or difficult discharge and transition plans are in place, or when barriers to accessing the next appropriate level of care arise.
Candidates must demonstrate a strong understanding of levels of care across the continuum, including inpatient acute hospital care, step-down settings, and post-acute services such as skilled nursing facilities, inpatient rehabilitation, long-term acute care, and home-based care. Experience navigating transitions from hospital settings to post-acute environments is essential.
In addition, candidates must have a solid managed care understanding, including how authorizations, utilization management criteria, medical necessity, and benefit structures impact transitions of care and placement decisions.
This role will track long-stay members and proactively support movement to the next appropriate level of care, collaborating closely with Utilization Management, Appeals and Grievance, Care Management, and Medical Director teams to resolve clinical, operational, and payer-related barriers to successful transitions.
Essential Functions
-In conjunction with other team members, ensures that transitional needs and barriers are resolved in a timely manner to meet regulatory timeframes.
-Directly interact with providers and their staff to obtain additional clinical information, as well as with members or their advocates to understand the full need to transition a member from one level of care to another.
-Review information and provide recommendations to the collaborative team based on analysis of the clinical material.
-Tracks and monitors the status of long-stay inpatient/post-acute cases, ensuring timely discharge planning.
-Identifies trends and patterns in discharge barriers with facilities and providers.
-Coordinates communication between patients, healthcare providers, and insurance companies regarding discharge needs.
-Coordinates communication with state and federal partners to ensure length of stay reporting is timely and accurate, and delivers follow-up information, as requested, by line of business or regulatory partners.
-Participates in interdisciplinary meetings to discuss complex cases and recommend solutions.
Qualifications
Education
- Associate’s Degree Nursing required or Bachelor’s Degree Healthcare Administration required or Bachelor’s Degree Related Field of Study required
Licenses and Credentials
- Massachusetts Registered Nurse [RN] license preferred
Experience
- At least 2-3 years of experience in health plan clinical services/utilization management required
- At least 2-3 years of clinical experience required
Knowledge, Skills, and Abilities
- Strong analytical and critical thinking skills.
- Excellent verbal and written communication abilities.
- Proficient in using electronic health records (EHR) and billing systems.
- Detail-oriented with strong organizational skills.
- Ability to handle sensitive information with confidentiality and professionalism.
- Strong interpersonal skills to work effectively with various stakeholders.
Additional Job Details (if applicable)
Working Conditions
- This is a remote role that can be done from most US states
Remote Type
Remote
Work Location
335 Revolution Drive
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
Pay Range
$79,560.00 – $115,720.80/Annual
Grade
7
At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.
EEO Statement:
8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
