Director of UM & Quality Programs
Harbor Health Services, Inc.
full-time
Posted on:
Location Type: Office
Location: Mattapan • Massachusetts • 🇺🇸 United States
Visit company websiteSalary
💰 $126,800 - $190,200 per year
Job Level
Lead
About the 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.
- 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.
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.
Benefits
- Health, Dental, Vision, Life, & Disability insurance
- 403b Savings Plan
- Generous Paid Time Off plus 11 additional Holidays and much more!
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
utilization managementquality improvementevidence-based guidelinesmedical managementmanaged care auditsclinical claims reviewchange managementdata analysisperformance metricshealth care resource management
Soft skills
leadershipcollaborationcommunicationproblem-solvingattention to detailorganizational skillsstrategic planninginterpersonal skillspresentation skillscontinuous learning
Certifications
Bachelor's DegreeNursing degreeMaster's degreeHealth Care Management degreeMSNMBAMPHMHSMHAmanagement certification