Director of UM & Quality Programs ESP

Harbor Health operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly, a program that allows frail elders to live in their homes and communities. Our Elder Service Plan has two medical and day centers in Mattapan and Brockton, MA and cares for more than 580 participants. We are currently seeking a Director of Utilization Management & Quality Programs.

Harbor Health offers an excellent, comprehensive benefits package including Health, Dental, Vision, Life, & Disability insurance, 403b Savings Plan, Generous Paid Time Off plus 11 additional Holidays and much more!

Role :

Reporting to the Senior Director of Health Plan Operations, the Director of Utilization Management and Quality Programs is responsible for the day-to-day support, direction and supervision of the overall utilization management function within the organization, as well as directing quality and process improvement activities to improve patient care and ensure efficient and cost-effective operations.

The Director of Utilization Management and Quality Programs develops systems, processes and best practices to address and monitor the efficient and effective use of health care resources, with attention to the quality and appropriateness of care within a managed care environment. Additionally, the Director of UM ensures that collaborative relationships are maintained with external entities (e.g., government agencies, vendors, providers, etc.) to ensure that objectives are aligned, strategies are implemented, and quality, financial, and compliance goals are met.

Responsibilities :

Utilization Management

• Partners across the organization and in particular, with the interdisciplinary team (IDT), to develop and implement strategies that reduce medical costs and improve health outcomes and maximize quality.
• Develops metrics to monitor and manage the performance of all utilization management functions and staff accountable for performance on such measures and prepares and presents data to PACE staff and Harbor leadership.
• Uses data to identify trends, develop improvement plans, and assess outcomes.
• Promotes the appropriate use of InterQual's medical management treatment guidelines.
• Ensures controls are established to maintain compliance with all contract requirements, as well as state and federal regulatory requirements; maintains audit-ready status.
• Creates a continuous learning culture and leads improvement of processes, policies, protocols, clinical guidelines and aligned business practices related to the UM function.
• Ensures timely responses to all requests related to medical review decisions and authorization issues from EOHHS, CMS and other regulatory entities.
• Collaborates with Senior Medical Director to resolve complex medical review issues and utilization cases requiring elevation to the Senior Medical Director.
• Provides organizational leadership and directs the development of new policies and reviews / modifies existing policies in collaboration with the Senior Medical Director, Senior Director of Clinical Operations and the Senior Vice President.
• Collaborates with leaders across the organization and serves as the organization's consultant regarding medical review process and UM regulations.
• Collaborates with providers to better understand provider experience and develops external partnerships with provider and healthcare organizations, including hospitals and SNFs.
• Serves as coach and clinical support to utilization team.
• Utilizes evidence-based standards and clinical expertise to review current role expectations, workflows, and standard operating procedures for gaps in care that may affect utilization.
• Performs clinical case reviews of high utilization cases and those upon request of utilization or finance department. Works with UM RNs and Senior Medical Director to deny claims when appropriate.
• Attends IDT meetings on routine basis.

Quality Management

Other Duties :

Requirements :

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

The salary range and / or hourly rate listed is a good faith determination of base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining actual base salary and / or rate, several factors may be considered as applicable (e.g. location, years of relevant experience, education, training, and other factors as permissible by law).

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