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Opportunity Snapshot

This position offers you the opportunity to "own" the full lifecycle management of retrospective review processes and join a ground floor team launching a new contract to conduct utilization review services for the MassHealth program.

You will enjoy the "best of both worlds:" the clinical sophistication of Permedion, a recognized leader in the assessment of healthcare services, and the resources and stability of Health Management Services (HMS), our parent corporation, recently ranked #3 on Fortune's 2009 FSB 100 list of America's fastest growing small public companies. If your current position requires evenings and weekends, you can look forward to a more regular schedule.

As Medical UR Manager, you will oversee all aspects of retrospective review, including recruiting, training and supervising a team of 17. This team will conduct inpatient and outpatient hospital reviews, inpatient rehabilitation reviews, concurrent reviews and conversion reviews.

Our Requirements

To be a good fit for this opportunity you will have:

• Massachusetts RN license and at least two years of management or supervisory experience.
• Strong background in utilization management, ideally in medical review, as well as experience with customer service and provider relations.
• The ability to recruit, hire, train and motivate.
• Knowledge in and successful application of basic level health care data analysis and clinical review.
• Solid computer savvy, including report generation experience, ideally with the MS Office Suite.
• Excellent interpersonal and communication skills, both written and oral.
• The flexibility to multitask and address diverse case types.

Preferred but not required:

• Experience with programs related to the Medicare Modernization Act or Medicaid Management Information Systems.
• Familiarity with Massachusetts rules and regulations on retrospective (prepayment and postpayment) review.
• Experience with concurrent review and/or rehab review.
• Experience working with physicians.

What's in It for You

Make your mark -- the retrospective component of this program will be your area to build and manage. In addition, you will be involved in some targeting decisions regarding trend analysis, such as ROI improvement analysis. As one of three Managers you will have input on the ongoing growth and development of the overall program.

Clinical sophistication through continuous improvement -- our URAC accreditation requires that we maintain continuous organizational improvement processes, and we never stop learning and growing. This spirit has enabled us to achieve industry recognition for our expertise. For example, we are designated by the Centers for Medicare and Medicaid Services (CMS) as one of eight Qualified Independent Contractors (QIC) in the US, meaning CMS acknowledges that we have the expertise and capabilities to perform appeals of Medicare claims between the carrier and Administrative Law Judge levels.

No signs of slowing -- Medicaid and Medicare budgets are growing (CMS predicts current Medicare/Medicaid spending levels to double by 2015) and, with billions of dollars at stake, there is a strong emphasis among policy leaders (and the voting public) on cost containment and payment accuracy. Permedion and HMS are taking advantage of this climate to drive solid growth. In addition to posting double-digit growth year over year since 2001, HMS is successfully expanding into new markets, including federal healthcare and managed care.

Great work environment -- you know that will be true as you'll play a key role in making that happen in the Charlestown facility. Throughout Permedion we maintain a congenial environment with a collaborative approach to achieving results.

Excellent compensation -- in addition to a competitive salary, we offer a comprehensive benefits package that includes 401(k) plan with generous employer match, flexible spending plans, and much more.

More About Your Role

On July 15, 2009 Permedion won the Massachusetts Acute Hospital Utilization Management Program contract with the University of Massachusetts, the agent administering the state's Medicaid program. In addition to the 30 professionals coming on board in facilities in Charlestown, MA, the program will take advantage of support and resources from other areas of Permedion.

Reporting to the Program Director, you will be one of three Managers; the other two will supervise Admissions Review and Provider Relations. Your first objective will be to recruit and train a team of Nurse Reviewers, Coding Specialists and Project Specialists, ensuring we are ready to start delivering on our contract commitments on November 2, 2009.

You will need to acquire a thorough knowledge of the contract and our deliverables, particularly as they pertain to retrospective review, and establish performance metrics and quality control standards for the team as well as each member. As you might expect, in the early stages you'll invest a good deal of your time in training. Once the program and your team are up and running, you will supervise them, act as a resource to resolve issues, and drive continuous improvement efforts.

In addition, you will act as the primary contact with physicians, including our Medical Director and Physician Panel, on more difficult cases. We'll look to you to exercise discretion in looking at a variety of case types as well as unique individual cases.

Keys to Success

Building a program from scratch takes a special kind of leader, one who can combine clinical knowledge, organizational skills, and the leadership and motivational skills to take a team to ever-higher levels of performance. To excel in this role you will have an outstanding ability to recognize talent during the interview process, as well as to develop that talent moving forward. You also will need to be comfortable with a degree of ambiguity as you help create the structure that will set us up for success in executing this contract beyond our client's expectations.

If this sounds like the right mix of challenge and opportunity for you, and you meet the minimum qualifications, we want to hear from you!

Who We Are

Permedion provides external medical peer reviews and independent health care review services for government agencies and large health care providers, helping them control escalating health care costs while providing appropriate medical care. Our three primary areas of service are health care quality measurement and improvement, data analysis and management, and independent medical review.

With a unique combination of statistical and clinical expertise, Permedion works with government agencies, managed care organizations, and other payors to review, measure and improve health care quality. Our staff includes physicians, nurses, epidemiologists and data analysts, systems experts, and health administration experts. Our partners and customers include health plans, physician groups, government agencies, and professional associations.

Permedion is a wholly owned subsidiary of Health Management Systems, Inc. (HMS), providing clinical expertise to all HMS service lines. HMS is an industry leader in the coordination of program integrity and benefits services for government healthcare programs. Since 1985 HMS has focused exclusively on the healthcare industry and during that time we have partnered with more than 45 Medicaid agencies, other state health programs, and more than 50 government-sponsored healthcare plans to help them recover billions of dollars, and save billions more through cost avoidance. Our portfolio of services includes coordination of benefits for Medicaid-Medicare, third-party liability, and pharmacy services; overpayment recovery; provider audits; medical support enforcement; and more.

We are an equal opportunity employer. EOE M/F/D/V

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