Overview Senior Director of Utilization Management RN — Veterans in Healthcare / Harbor Health Elder Service Plan (ESP) in Mattapan, MA. This role reports to the Senior Vice President of Harbor Health ESP and is responsible for strategic and operational leadership of the Utilization Management (UM) staff to ensure quality, appropriate healthcare services for ESP/PACE participants.
Role: The Senior Director of Utilization Management (SDUM) leads program design and development, collaborates with the Sr. Director of Clinical Operations, Director of Care Coordination, and Interdisciplinary Teams to ensure coordination, collaboration, and program consistency. Represents Harbor’s PACE program with government agencies, providers, hospitals, SNFs, and other external partners. Accountable for management and outcomes of medical expense relative to inpatient level of care within the PACE framework, guiding principles, and financial objectives.
Responsibilities Build out the UM Department to comprehensively address and monitor efficient and effective use of healthcare resources, focusing on quality and appropriateness of care within a managed care environment.
Provide organizational leadership and direct the development of policies, procedures, systems, and best practices to support a sophisticated UM model.
Collaborate with data analysts and the clinical applications team to identify data needs and EMR changes to track outcomes.
Use data to identify trends, develop improvement plans, assess outcomes, and present data to PACE staff and Harbor leadership.
Coordinate, oversee, and facilitate the monthly Medical Expense Management meeting.
Provide direct oversight of the UM team including UM Nurses and administrative staff; manage day-to-day UM operations.
Develop, integrate, and implement all components of a utilization management program, fostering a culture of high reliability.
Partner across the organization and with the IDT to reduce medical costs and improve health outcomes.
Act as liaison to external care partners (physicians, case managers, nursing, community agencies, inpatient facilities) to facilitate communication and collaboration.
Lead strategies to improve patient length of stay, clinical documentation, and timely authorizations for quality and patient safety.
Collaborate with providers and external partners to understand provider experience and develop partnerships with hospitals and SNFs.
Implement, train, and roll out medical management guidelines (e.g., InterQual, Milliman).
Ensure controls to maintain compliance with contract, state, and federal regulatory requirements; maintain audit-ready status.
Create a continuous learning culture and lead improvement of UM-related processes, policies, protocols, and clinical guidelines.
Ensure timely responses to medical review decisions and authorization inquiries from EOHHS, CMS, and other regulators.
Collaborate with the Senior Medical Director to resolve complex medical review issues and escalate as needed.
Serve as the organization’s UM subject matter expert; advise leaders on medical review processes and UM regulations.
Lead administrative budget development and monitoring for the UM function; monitor performance and manage staff development and succession planning.
Coach and provide clinical support to the utilization team; drive quality improvements and consistency of decisions.
Coordinate with the Director of Quality and Compliance and vendors in quality improvement and adherence to practice standards and PACE requirements.
Review current role expectations, workflows, and SOPs to identify gaps in care affecting utilization.
Perform clinical case reviews of high-utilization cases; collaborate with UM RNs and the Senior Medical Director on appropriate claim denials.
Attend IDT meetings on a routine basis.
Qualifications Bachelor of Science in Nursing required; current Massachusetts RN license.
Current BLS (Basic Life Support for Health Care Providers) certification.
Advanced degree strongly preferred (MBA, MPH, MHS, or MHA).
8+ years of management experience in a health plan and/or managed care environment.
Knowledge of evidence-based guideline tools (InterQual, Milliman) for utilization management.
Experience with managed care audits and reviews; applying medical management guidelines (InterQual, Milliman).
Experience with change and organization management; knowledge of UM/CM, Grievance and Appeals, inpatient/outpatient services, medical policy, and clinical claims review.
In-depth knowledge of Mass Health and CMS requirements; experience managing care information systems.
MS Office 365 proficiency (Word, Excel, Outlook, Teams).
Strong interpersonal, written, and verbal communication skills; highly organized with attention to detail.
Willingness and ability to travel between Harbor sites and to outside contracted agencies as required.
Supervisory responsibilities include 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.
Schedule: Monday through Friday 8:30 AM - 5:00 PM; Hybrid; 40 hours.
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