Director of Utilization Management, SCO and One Care Plans

Title: Director of Utilization Management, SCO and One Care Plans
Reports to: Senior Medical Director
Classification: Director
Location: Boston (Hybrid)
Job description revision number and date: V 2.0; 12.09.2024

Organization Summary:

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

SCO and One Care Summary

The Senior Care Options (SCO) and One Care programs are health plan programs for dually eligible (Medicare and Medicaid) individuals (“duals”) in Massachusetts. SCO serves eligible beneficiaries aged 65 , while One Care serves duals between ages 21-64. These programs are Fully Integrated Dual-Eligible Special Needs Plans (FIDE- SNP) that integrate Medicare and Medicaid benefits, along with additional supports for enrollees such as integrated care teams, care managers, social supports, etc.

Massachusetts’ Medicaid (MassHealth) agency recently conducted a procurement for health plans to offer products in these two programs, for a five-year term starting January 1, 2026. C3 submitted a bid and was selected in September 2024.

Job Summary:

Reporting to Senior Medical Director, The Director of Utilization Management, SCO and OneCare Plans, oversees the design, strategic planning, development, implementation, and administration of all aspects of the nascent SCO and One Care utilization management (UM) programs. This Director will be an early hire in a start-up health plan with an operational “go-live” date of January 01, 2026 with open enrollment beginning October 2025. The scope includes evaluation and implementation of technologies that establish the workflows of and improve the efficiency, quality, and accuracy of UM decisions. This work will also include establishing the initial and ongoing universe of services and codes subject to UM review within the SCO and One Care portfolios. The Director is responsible for assuring members receive high quality and appropriate services in a timely, outcomes-based, and cost-effective manner based on our benefit design and authorization structure. The Director will also be responsible for developing strong cost and quality oversight procedures for the UM program and for any UM vendor or delegated partner. This includes the development of prior authorization, medical necessity criteria, and reporting structure. The Director will build a team of utilization management professionals, provide guidance on complex cases, and communicate effectively with stakeholders. This role requires collaboration with various stakeholders, including close collaboration with the Chief Medical Officer, Senior Medical Director, and the Executive Director, SCO and One Care Plans, to enhance the quality and efficiency of services delivered to our members and ensure overall member satisfaction.

Responsibilities:

• Development of a Utilization Management program and building of a team that meets compliance standards for service decisions and organizational determinations, including ensure timely and accurate communications of medical necessity review results to the original requester in compliance with regulatory and contractual requirements
• Creation of a portfolio of services subject to UM meeting the regulatory requirements of the Medicare and MassHealth programs under the FIDE-SNP umbrella
• Accountability for an effective interdepartmental process for the clarification, configuration, and communication of Utilization Management policies and procedures for internal and external customers
• Responsible for supporting cross-functional team decision making regarding Utilization policies, configuring business requirements, and developing test cases for the Health Axis claims engine application
• Support the development, implementation, and maintenance of a process to align benefits, coverage, medical policy, and payment decisions across operational areas including an appeals and grievances process, clinical team, integrated care team, care management, provider network (contracted) team, audit team, finance team, and compliance team
• Ensure the right systems, processes, measurements, and reporting are in place to demonstrate the value and clinical effectiveness of utilization management programs to internal and external customers
• Represent C3 to a variety of external stakeholders including provider organizations, customers, advocacy groups and government entities as needed
• Manage relationships and operations with external partners and vendors that provide services as part of the Utilization Management program
• Meet applicable regulatory and compliance standards and accreditation requirements by maintaining a continuous quality improvement program to aid external and internal audits
• Responsible for assuring the documentation, ongoing monitoring, and development of training materials and training of departmental staff in utilization management guidelines and processes
• Work in partnership with the C3 technical team and vendors to improve system efficiency and remains current on industry trends and technologies
• Establishes department goals and performance metrics that assists the department and enterprise strategic plans
• Manage department budget
• In all matters, supports the culture and mission of C3, including but not limited to:
  • Communicates organizational and divisional information to staff on a regular and timely basis to ensure consistency of understanding of goals, priorities, and organizational direction
  • Incorporates organizational key messages in communications
  • Develops and implements a method of providing regular feedback on the status of projects requested and implemented
  • Serve as an organizational champion for the company’s work on Diversity, Equity and Racial Justice

• Other duties as assigned

Required Skills:

• Management/supervisory experience, 5 or more years
• Progressive leadership experience in utilization management
• 3 years’ experience working in or with utilization management experience
• Previous experience working in a health plan, specifically with utilization management, including development of policies, procedures, and medical necessity criteria, required
• Clinical experience is preferred
• Requires research and analytic skills and an ability to oversee, understand, and articulate the results of the research and analysis to perform many of the responsibilities outlined above
• Knowledge and understanding of regulatory language
• Excellent oral and written communications skills
• Experience managing cross functional projects
• Knowledge of managed care health plans operations and HIPAA guidelines
• Proven skills and judgment necessary for independent decision-making
• Experience and knowledge in intermediate computer skills and proficient in Microsoft Office Suite or related software
• Excellent verbal and written communication skills
• Excellent ability to develop orderly processes to accomplish those goals
• Must be able to remain in a stationary position 50-75% of the time
  

Desired Other Skills:

• Familiarity with Utilization Management for surgical procedures, Medicare and MassHealth rules, Medicare Part B medications, long term services and supports (LTSS), and home health (HH)
• Familiarity with Federally Qualified Health Centers
• Experience managing large, cross-team projects
• History of accountability for an area with a high degree of regulatory compliance complexity, ideally for dually-eligible-specific compliance or at least Medicaid and/or Medicare compliance
• Familiarity with the MassHealth ACO program
• Familiarity with Federally Qualified Health Centers
• Experience with anti-racism activities, and/or lived experience with racism is highly preferred

Qualifications:

• Bachelor’s level degree in Nursing, Public Health, Public Administration, or equivalent in a related field (ex. DPT, PharmD)
• Masters in a relevant field, such as Public Health, Public Administration, Business Administration, preferred but not required
• Active clinical licensure in the state of Massachusetts or ability to obtain is preferred

** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **