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Regional Utilization Management Director

2 months ago

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

As a Regional Utilization Management Director at Kaiser Permanente, you will provide strategic leadership for joint Health Plan/TSPMG management efforts related to appropriate utilization of hospitals and specialty care. You will monitor transition of care, continuing care/sub-acute care resources, non-core hospital oversight to UM/case management, and manage referrals to maximize the quality and efficiency of care provided to our members.

Key Responsibilities
  • Develop and Direct Utilization Management Programs: Provide leadership in the development, direction, and evaluation of an effective regional utilization management program that supports the delivery of high-quality healthcare in the most appropriate and cost-effective manner.
  • Ensure Smooth Integration of Member Care: Provide 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.
  • Partner with Regional and Service Area Leadership: Partner with regional and service area leadership as well as healthcare teams to ensure that required internal systems and processes to manage high-risk, high-cost care needs are delivered effectively.
  • Lead Complex Systems and Change Management: Leadership acumen directing teams in complex systems, including change management efforts. Ability to work in a highly matrixed system of care and decision-making.
  • Develop Systems for Effective Coordination: Develop systems to ensure effective coordination and integration between Utilization Management functions and Clinical Review, Contracting, and Claims Processes.
  • Represent the Region in Regulatory and Legislative Arenas: Represent the region in utilization management in regulatory, licensing, and legislative arenas, such as NCQA, CMS, State, or other employer requirements.
  • Provide Leadership and Direction for Health Plan Integration: Provide leadership and direction for health plan integration with other agencies or 3rd party administrators who participate in utilization management for our members.
  • Accountable for Administrative Leadership and Budgetary Responsibility: Accountable for the administrative leadership and budgetary responsibility for the team of staff that support these functions in the department.
  • Ensure Quality Oversight of Contracted and Internal Services: Ensure the quality oversight of contracted and internal services in the continuum of care.
  • Manage Vendor Relationships: Manage vendor relationships such as those involving DME and transportation vendors to ensure timely feedback and performance that meets service level agreements.
  • Lead Strategic Thinking and Planning: Lead 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.
  • Ensure Operational Efficiency of the Continuum: Ensure the operational efficiency of the Continuum to produce timely and accurate disposition of referrals for outpatient and post-acute services.
  • Establish and Drive Distinct Workflows: Establish and drive distinct workflows for pre-patriation and repatriation, deliberately directing member care to and through KP-preferred network providers when clinically appropriate/reasonable.
  • Provide Leadership and Direction in Identifying Operational Barriers: Provide leadership and direction in the identification, documentation, and resolution of operational barriers that interfere with seamless care coordination to members.
  • Collaborate with Member Appeals: Collaborate with member appeals.
  • Manage Regulatory Turnaround for Processing Referrals and/or Denials or Appeals: Manage regulatory turnaround for processing referrals and/or denials or appeals with relevant parties.
  • Participate and Lead QRM Involvement Related to Tricare, Duals & Related Products: Participate and lead QRM involvement related to Tricare, Duals & related products.
Requirements
  • Minimum Ten Years of Multi-Faceted Healthcare System Management Experience: Minimum ten (10) years of multi-faceted healthcare system management experience with at least five (5) years within a health plan setting.
  • Masters Degree in Healthcare Administration, Nursing, Business, or Related Field: Masters Degree required in Healthcare Administration, Nursing, Business, or related field OR Bachelors degree in Healthcare Administration, Nursing, Business, or related field.
  • Thorough Knowledge of Quality Assurance, Quality Improvement, Utilization Review, Risk Management, and Accreditation and Licensing 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: Track record achieving superior results that demonstrate performance improvement and quality and service outcomes.
  • Ability to Work in a Labor/Management Partnership Environment: Must be able to work in a Labor/Management Partnership environment.