Utilization Management Home Health Manager

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

This role serves as a key clinical decision-maker, exercising independent judgment and critical thinking in the evaluation of home health service requests. The role requires a proactive and analytical approach to service delivery, with a focus on clinical quality and compliance. The Home Health Manager is responsible for the oversight, coordination, and performance of home health services within the Managed Care Organization. This role ensures home health services are provided effectively, efficiently, and in compliance with regulatory, accreditation, and contractual standards. The Home Health Manager collaborates closely with internal departments, provider networks, and external vendors to manage utilization, improve quality of care, and ensure positive member outcomes.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Responsibilities:

* Oversee home health operations and compliance for Medicaid, Medicare, and ACA lines of business, ensuring alignment with regulatory, contractual, and accreditation requirements.

* Manage and support home health services across the states of Massachusetts and New Hampshire, accounting for state-specific guidelines, workflows, and provider networks.

* Oversee daily operations of the home health service line, including prior authorization, care coordination, and vendor/provider performance.

* Ensure timely and appropriate delivery of home health services to members based on medical necessity and clinical guidelines.

* Lead home health interdisciplinary rounds and provide Utilization Management staff with education and guidance on reviewing and interpreting home health documentation for medical necessity and compliance.

* Collaborate with Utilization Management (UM), Case Management (CM), and Quality teams to align services with member needs and organizational goals.

* Collaborate closely with Medical Directors to review complex cases, ensure alignment with clinical guidelines, and support appropriate and timely decision-making related to home health services.

* Monitor provider performance, including adherence to service level agreements, quality metrics, timeliness, and compliance requirements.

* Evaluate home health referrals and ensure they meet medical necessity criteria; assist staff with complex cases and escalations.

* Develop and maintain policies, workflows, and procedures related to home health care in accordance with NCQA, CMS, and state-specific standards.

* Educate providers, internal staff, and external stakeholders on home health protocols, documentation requirements, and process expectations.

* Participate in audits, readiness reviews, and quality improvement initiatives as they relate to home health services.

* Analyze trends in utilization, cost, and member outcomes to identify opportunities for improvement.

* Serve as a subject matter expert (SME) on home health services and represent the department in cross-functional meetings and projects.

* Provide strategic leadership and direction to a multidisciplinary team of clinical and non-clinical professionals, cultivating a culture of collaboration, accountability, and operational excellence.

* Oversee the training, development, and performance evaluation of direct reports, ensuring staff competency, adherence to organizational policies, and continuous improvement aligned with departmental goals and quality standards

Qualifications:

Educational Requirements:

* Bachelor's degree in nursing, Health Administration, Public Health, or a related field required.

* RN license strongly preferred.

* Master's degree a plus.

Experience:

* Minimum of 5 years of clinical experience in home health, including at least 3 years in a managed care or payer setting.

* Supervisory or management experience required.

* Knowledge of Medicaid, Medicare, and ACA managed care regulations in utilization management and medical necessity.

Preferred Qualifications:

* Experience working with Child and Adolescent Behavioral Health Services and/or Substance Use Disorder Services.

• Familiarity with managed care principles and regulatory compliance requirements.

Licensure and Certification:

* Active, unrestricted RN License

* Willing to obtain RN licensure in MA and NH.

Core Competencies:

* Strong knowledge of home health regulations, documentation standards, and accreditation requirements.

* Proficient in interpreting medical records, clinical criteria (e.g., InterQual, NCD, LCD), and home health care plans.

* Excellent leadership, communication, and interpersonal skills.

* Ability to manage multiple priorities in a fast-paced, regulatory-driven environment.

* Proficient in Microsoft Office, and claims and medical management platforms (e.g. Jiva, facets).

Work Environment and Physical Demands:

• Primarily remote role with periodic travel to the Charlestown, MA office for team meetings and training sessions.
• Dynamic and fast-paced work setting requiring adaptability and resilience.
• Minimal physical exertion required; standard office tasks such as typing and phone use.
• Consistent and reliable attendance is an essential job requirement.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees