Description

Harbor Health operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly (PACE), 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 Senior Director of Utilization Management RN to join our team.  

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 Vice President of the Harbor Health Elder Service Plan (ESP), the Senior Director of Utilization Management (SDUM) is responsible for the strategic and operational leadership of the UM staff in ensuring the delivery of quality and appropriate healthcare services to Elder Service Plan/PACE participants. The SDUM maintains a solid grasp of the national healthcare industry, best practices, and provides leadership to program design and development, works closely with the Sr. Director of Clinical Operations, the Director of Care Coordination, and the Interdisciplinary Teams to ensure coordination, collaboration and program consistency. The SDUM represents Harbor's PACE program as a senior leader with government agencies, providers, hospitals, skilled nursing facilities and other external partners and is accountable for the management and outcomes of medical expense relative to any inpatient level of care within the PACE vision, guiding principles, and financial objectives.

• Responsible for building out the existing UM Department to more comprehensively 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.
• Provides organizational leadership and directs the development of policies, procedures, systems, and best practices to support the higher level of operations necessary to implement a more sophisticated UM model.
• Collaborates with data analysts and clinical applications team to identify evolving data needs and Electronic Medical Record (EMR) changes necessary to track and monitor outcomes.
• Uses data to identify trends, develop improvement plans and assess outcomes and prepares and presents the data to PACE staff and Harbor leadership.
  Coordinates, oversees and facilitates the monthly Medical Expense Management meeting.
• Provides direct oversight of the UM team including UM Nurses and administrative staff.
• Responsible for the day-to-day support, direction, and supervision of the overall UM function within the organization.
• Develops, integrates, and implements all components of a utilization management program including a culture of high reliability.
• Partners across the organization and with the interdisciplinary team (IDT) to develop and implement strategies that reduce medical costs and improve health outcomes. 
• Acts as a liaison to facilitate communication and collaboration between all external care partners (physicians, case managers, nursing, community agencies, and inpatient facilities).
• Participates in this evolutionary process by continuously developing and leading robust strategies and operational efficiencies designed to improve patient length of stay, improved clinical documentation and timely authorizations for improved quality and patient safety.
• Collaborates with providers to better understand provider experience and develops external partnerships with provider and healthcare organizations, including hospitals and SNFs.
• Implement, train and rolls-out the use of medical management treatment guidelines, such as InterQual or Milliman.
• Ensures controls are established to maintain compliance with all contract requirements, as well as state and federal regulatory requirements; maintain audit-ready status.
• Creates a continuous learning culture and lead improvement of processes, policies, protocols, clinical guidelines and aligned business practices related to the UM function.
• Ensure timely responses to all requests related to medical review decisions and authorization issues from EOHHS, CMS and other regulatory entities.
• Collaborates with the Senior Medical Director to resolve complex medical review issues and on utilization cases requiring elevation to Medical Director.
• Collaborates with leaders across the organization and serve as the organization’s consultant and subject matter expert regarding medical review process and UM regulations.
• Leads administrative budget development and monitoring for area of responsibility.
• Engages in ongoing performance management with staff including coaching, mentoring, development and succession planning.
  Monitors performance and staff decision-making and drive improvements in quality and consistency of decisions.
• Serves as coach and clinical support to utilization team.
• In collaboration with the Director of Quality and Compliance, engages associated vendors in continuous quality improvement through communication of practice standards, PACE, and through an internal quality assurance program that measures vendor performance.
• 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 and works with UM RNs and Senior Medical Director to deny claims when appropriate.
• Attend IDT meetings on routine basis.

Requirements

Requirements: 

• Bachelors of Science in Nursing required, current Massachusetts Registered Nurse (RN) License
• Current BLS (Basic Life Support for Health Care Providers) Certification
• Advanced degree in health care management (MBA, MPH, MHS, or MHA) strongly preferred
• 8+ years of management experience in a health plan and/or managed care environment required
• Knowledge of evidence-based guideline tools (InterQual, Milliman) for utilization management
• Experience with managed care audits and reviews
• Experience applying medical management treatment guidelines, such as InterQual, Milliman, or other practical management guidelines
  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 managing care information systems
• Intermediate/Advanced knowledge of MS Office 365 including Word, Excel, Outlook and Teams
• Great interpersonal skills, 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 as required in a timely manner
• Supervisory responsibilities  includes oversight of UM Nurse Team and administrative staff

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