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 In collaboration with the Senior Director of Health Plan Operations and working closely with the Senior Medical Director, develops and oversees the annual Quality Improvement plan. Oversees the collection of quality measures and other data by the Quality Analyst for report to regulatory agencies, including CMS and MassHealth. Supports follow-up of corrective action plans. Analyzes and trends quality data to identify areas requiring improvement and oversees quality improvement activities. Facilitates the monthly ESP Quality Improvement meetings. Responsible for preparing and presenting ESP’s most recent quality data to the Quality Improvement and Compliance Committee (QICC) – a subcommittee of the Board. In collaboration with the Quality Analyst, oversees preparation of reports for the ESP QI Meeting, HHSI Quality Steering Committee, QICC and regulatory agencies. Engages associated vendors in continuous quality improvement through communication of practice standards, PACE, and through an internal quality assurance program that measures vendor performance. Assists managers in the following activities : training and education, key process improvement, communication to employees about QI efforts. Working with the Appeals and Grievances Specialist, maintains oversight of the Grievances and Appeals process, including timely investigations, responses, and reporting to CMS. Oversees the process for CMS reportable events. Responsible for oversight of the Health Outcomes Survey (HOS-M) and the quarterly Participant Advisory Committee (PAC) meetings and to review outcomes for report out at QIC. Leads administrative budget development and monitoring for areas of responsibility. Other Duties : Engages in ongoing performance management with staff including coaching, mentoring, development and succession planning. Monitors performance and staff decision-making and drives improvements in quality and consistency of decisions. Supervisory responsibilities for UM RN, Quality Analyst, Appeals and Grievances Specialist. Requirements : Bachelor’s Degree required, Nursing degree strongly preferred Master’s degree and / or Health Care Management degree (MSN, MBA, MPH, MHS, or MHA) strongly preferred 5 or more years of management experience in a health plan and / or managed care environment required 3 or more years of supervisory experience preferred Knowledge of evidence-based guideline tools (InterQual, Milliman) for utilization management required Experience with managed care audits and reviews Experience applying medical management treatment guidelines, such as InterQual, Milliman, or other practical management guidelines Demonstrated Knowledge of Quality Improvement processes, including problem-solving models, methods and tools required Experience with change and organization management In-depth knowledge of all aspects of managed care medical management including UM / CM, Grievance and Appeals, inpatient and outpatient services, medical policy, and clinical claims review In-depth experience of Mass Health and CMS requirements Knowledge of and experience utilizing Electronic Medical Record (EPIC preferred) Intermediate knowledge of Office 365 including Word, Excel, Outlook and Teams Excellent written and verbal communication skills Strong attention to detail and highly organized Must be able to travel between Harbor sites and to outside contracted agencies in a timely manner 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).