Integra Partners is a leading, tech-enabled, healthcare benefit management company focused on community-based care. Integra has a core competency in Durable Medical Equipment (DME), Orthotics and Prosthetics (O&P), and works with providers and health plans to facilitate care for hundreds of thousands of patients each year. We have experienced rapid growth with no slowdown in sight.
Our leadership team is amazing (www.accessintegra.com) and focused on what really matters to our business - every employee, every experience, and every customer. With the right people, success is unbounded. This is a truly unique opportunity to take a position with a great company, surrounded by an awesome team.
In 2015, Integra’s management and Tufts Health Plan of Massachusetts acquired the business. Tufts Health Plan is one of the country’s leading, 5-star, private health plans providing healthcare to individuals and employer groups. Integra now operates as a separate financial investment and subsidiary of Tufts Health Plan with a separate board of directors and governance structure. Integra is an innovative and exciting company, with an entrepreneurial culture focused on teamwork and everyday excellence.
Scope and Responsibility
Integra’s benefit management division, DMEnsion, is looking for an experienced individual to help build, maintain, and manage the utilization management department. This individual will play a key role in delivering UM to our health plan clients, growing our UM business, and working with the rest of the organization to operationalize our UM program.
Key Responsibilities and Essential Functions
- Responsible for meeting accrediting agency standards, such as NCQA and URAC, and third party payor programs
- Prepare and maintain UM Plan policies and procedures in conjunction with Medical Director
- Work with Medical Director to establish, adopt, and review UM benefit and medical necessity decision-making criteria
- Supervise and train UM Department, clinical and non-clinical staff, to ensure timely review of prior authorization, concurrent, and retrospective UM functions
- Ensure availability to UM staff on site or by telephone
- Gather all pertinent information for UM decision-making and ensure all aspects of process are documented in cases
- Review requests against adopted evidence-based criteria and approve requests that meet eligibility, benefit, and medical necessity criteria
- Refer cases that do not meet medical necessity criteria, or cases in which member’s individual situation or the local delivery system render the criteria inappropriate, to the Medical Director for review
- Responsible for UM-related quality improvement activities, including conducting audits to ensure consistent application of medical criteria and evaluating program for improvement opportunities
- Serve as internal support staff to physician advisory committee and external liaison for clients to ensure program meets contractual delegated activities and performance requirements
- Participate in technology related activities and implement solutions across UM Department
- Oversee and execute the workplan to achieve NCQA certification
- Build and manage the administrative and clinical resources to ensure the UM program functions efficiently and effectively, meeting all internal, legal, regulatory, and/or certification standards
- Build and maintain a staffing model that is flexible and appropriate to scale as the business scales
- Manage internal policies and procedures to ensure compliance, effectiveness, and best in class clinical operations
- Owner of the third party technology and configuration of medical management software to ensure optimal operation
- Responsible for day to day team management to ensure on-time, on-budget delivery of all operations
- Active registered nurse license
- Minimum of 5 years of UM management experience in a managed care setting
- Experience with UM NCQA or URAC certification/accreditation
- Analytical ability and clinical knowledge in order to assess medical records, identify trends, and report findings
- Communication skills, verbal and written, needed to convey information clearly and consistently
- Interpersonal skills necessary to develop and maintain a wide variety of cooperative working relationships
- Bachelor’s degree in area of specialty, preferred
It is the policy of Integra Partners to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Integra Partners will provide reasonable accommodations for qualified individuals with disabilities.