Quality Risk Management & Outside Services Senior Director (RN strongly preferred)
Company: Health eCareers
Location: Atlanta
Posted on: October 3, 2024
Job Description:
Job SummaryProvides regional leadership for joint Health
Plan/TSPMG management efforts related to appropriate utilization of
hospitals and specialty care, monitors transition of care,
continuing care/sub-acute care resources, non-core hospital
oversight to UM/case management, and manages referrals to maximize
the quality and efficiency of care provided to our members.
Oversight to repatriation process of bringing KP members to KP
facilities and services when appropriate. Ensures that processes
and systems are implemented for the patient to enter care at the
optimal point in the care continuum and accesses appropriate levels
of care with the goal of maximizing health status outcomes. Has a
matrix relationship with TSPMG leaders and physicians to carry out
the priorities defined by the health plan.Essential
Responsibilities
- Provides leadership in the development, direction and
evaluation of an effective regional utilization management program
that supports the delivery of high-quality health care in the most
appropriate and cost-effective manner. Provides consultation and
support for health plan and medical group utilization review
activities that influence medical and clinical outcomes.
- Provides leadership in ensuring appropriate mechanisms and
systems are in place to ensure the smooth integration of member
care between hospitals, sub-acute, skilled nursing, ambulatory and
home care for example. Builds effective partnerships with other
leaders and functions to ensure integration occurs. Represents the
organization nonoperational relationships in partnership with other
Continuum leaders as it pertains to hospitals, skilled nursing or
rehab facilities, as well as with other network
providers/practitioners.
- Partners with regional and service area leadership as well as
health care teams to ensure that required internal systems and
processes to manage the high risk, high cost of care needs are
delivered effectively and that they are supported, monitored and
evaluated on an ongoing basis.
- Leadership acumen directing teams in complex systems, including
change management efforts. Ability to work in a highly matrixed
system of care and decision making.
- Develops systems to ensure effective coordination and
integration between Utilization Management functions and Clinical
Review, Contracting, and Claims Processes. Works collaboratively
with other key TSPMG/Health Plan leaders to ensure that the
processes exist that will result in benefits that are delivered and
paid appropriately in accordance with contractual provisions and in
the best interest of the patient.
- Represents the region in utilization management in regulatory,
licensing and legislative arenas, such as NCQA, CMS, State or other
employer requirements. Prepares and presents information and
testimony to ensure compliance with medical guidelines and
procedures required by both KP internally and/or outside accredited
agencies.
- Provides leadership and direction for health plan integration
with other agencies or 3rd party administrators who participate in
utilization management for our members in delegated or
non-delegated relationships, i.e. Harrington Health, PHOs,
etc.
- Accountable for the administrative leadership and budgetary
responsibility for the team of staff that support these functions
in the department. Ensures that their functions are aligned with
and supportive of the overall operational leadership goals.
- Ensures the quality oversight of contracted and internal
services in the continuum of care.
- Manages Vendor relationships such as those involving DME and
transportation vendor to ensure timely feedback and performance
that meets service level agreements.
- Leads strategic thinking and planning on how best to structure
the QRM/Referrals/Outside Services team and processes for optimal
performance in meeting the needs of our members, physicians and
organization at large.
- Ensures the operational efficiency of the Continuum to produce
timely and accurate disposition of referrals for outpatient and
post-acute services.
- In conjunction with TSPMG, establishes and drives distinct
workflows for pre-patriation and repatriation, deliberately
directing members care to and through KP-preferred network
providers when clinically appropriate/reasonable.
- Provides leadership and direction in the identification,
documentation and resolution of operational barriers that interfere
with seamless care coordination to members.
- Collaborates with member appeals.
- Manages regulatory turn around for processing referrals and/or
denials or appeals with relevant parties.
- Participates and leads QRM involvement related to Tricare,
Duals & related products.ExperienceBasic Qualifications:
- Minimum ten (10) years of multi-faceted health care system
management experience with at least five (5) years within a health
plan setting.Education
- Masters Degree required in Health Care Administration, Nursing,
Business or related field OR Bachelors degree in Health Care
Administration, Nursing, Business or related field.License,
Certification, Registration
- N/AAdditional Requirements
- Thorough knowledge of quality assurance, quality improvement,
utilization review, risk management, and accreditation and
licensing requirements including NCQA, Knox-Keene Act, Federal HMO
Act, CMS, HIPAA and related regulatory bodies.
- Track record achieving superior results that demonstrate
performance improvement and quality and service outcomes.
- Must be able to work in a Labor/Management Partnership
environment.Preferred Qualifications
- Clinical license such as RN preferred but not required.
- Another professional licenses desirable including but not
limited to: Pharm D, NP, PA, JD, PhD, MD, EDS.
- Case management and utilization management experience
Keywords: Health eCareers, Johns Creek , Quality Risk Management & Outside Services Senior Director (RN strongly preferred), Executive , Atlanta, Georgia
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