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Regional Utilization Management Director

2 months ago

Atlanta, Georgia, United States Kaiser Permanente Full time
Job Summary

Kaiser Permanente is seeking a highly experienced and skilled Regional Utilization Management Director to provide leadership and direction for our regional utilization management program. This individual will be responsible for ensuring that our members receive high-quality healthcare in the most appropriate and cost-effective manner.

Key Responsibilities
  • Leadership and Direction: Provide leadership and direction for the development, implementation, and evaluation of an effective regional utilization management program.
  • Program Development: Develop and implement programs to ensure the smooth integration of member care between hospitals, sub-acute, skilled nursing, ambulatory, and home care.
  • Partnerships and Collaboration: Build and maintain effective partnerships with other leaders and functions to ensure integration occurs and represent the organization in non-operational relationships.
  • Regulatory Compliance: Ensure compliance with regulatory requirements, including NCQA, CMS, State, and other employer requirements.
  • Vendor Management: Manage vendor relationships, including DME and transportation vendors, to ensure timely feedback and performance that meets service level agreements.
  • Strategic Planning: Lead strategic thinking and planning on how best to structure the QRM/Referrals/Outside Services team and processes for optimal performance.
  • Operational Efficiency: Ensure the operational efficiency of the Continuum to produce timely and accurate disposition of referrals for outpatient and post-acute services.
  • Care Coordination: Provide leadership and direction in the identification, documentation, and resolution of operational barriers that interfere with seamless care coordination to members.
  • Regulatory Turnaround: Manage regulatory turnaround for processing referrals and/or denials or appeals with relevant parties.
  • Quality Improvement: Participate and lead QRM involvement related to Tricare, Duals, and related products.
Requirements
  • Experience: Minimum ten (10) years of multi-faceted healthcare system management experience with at least five (5) years within a health plan setting.
  • Education: Masters Degree required in Healthcare Administration, Nursing, Business, or related field OR Bachelors degree in Healthcare Administration, Nursing, Business, or related field.
  • Additional Requirements: Thorough knowledge of quality assurance, quality improvement, utilization review, risk management, and accreditation and licensing requirements.