Harbor Health Services, Inc.

Director

• 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.
• 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.
• 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.
• 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.
• Creates a continuous learning culture and leads improvement of processes, policies, protocols, clinical guidelines and aligned business practices related to the UM function.

Director of UM & Quality Programs