Veterans in Healthcare · 1 month ago
Director of UM & Quality Programs ESP
Boston, MA
Full-time
Onsite
Lead/Staff, Director/Executive
$127K/yr - $190K/yr
5+ years expVeterans in Healthcare is seeking a Director of Utilization Management & Quality Programs to oversee the utilization management function and quality improvement activities within the organization. This role involves developing systems and processes to ensure efficient healthcare resource use while maintaining high-quality patient care.
Health CareMilitary
Responsibilities
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
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
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
Qualification
Required
Bachelor's Degree required, Nursing degree strongly preferred
5 or more 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 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
Preferred
Master's degree and/or Health Care Management degree (MSN, MBA, MPH, MHS, or MHA) strongly preferred
3 or more years of supervisory experience preferred
Benefits
Health, Dental, Vision, Life, & Disability insurance
403b Savings Plan
Generous Paid Time Off plus 11 additional Holidays
Company
Veterans in Healthcare
Veterans in Healthcare is a comprehensive source of career information and opportunities for military personnel transitioning.
2-10 employees
Funding
Current Stage
Early StageCompany data provided by crunchbase