Quality Risk Management Director

6 days ago


Atlanta, Georgia, United States Health eCareers Full time
Job Summary

We are seeking a highly skilled and experienced professional to lead our Quality Risk Management (QRM) team. As a Regional Care Coordination Leader, you will be responsible for developing and implementing effective regional utilization management programs that support the delivery of high-quality healthcare in the most appropriate and cost-effective manner.

Key Responsibilities
  • Provide leadership in the development, direction, and evaluation of regional utilization management programs that promote high-quality healthcare and cost-effectiveness.
  • Collaborate with regional and service area leadership, as well as healthcare teams, to ensure that required internal systems and processes are in place to manage high-risk, high-cost care needs.
  • Develop and implement systems to ensure effective coordination and integration between Utilization Management functions and Clinical Review, Contracting, and Claims Processes.
  • Represent the region in utilization management in regulatory, licensing, and legislative arenas, such as NCQA, CMS, and State or other employer requirements.
  • 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 the administrative leadership and budgetary responsibility for the team of staff that support these functions in the department.
Requirements
  • Minimum ten (10) years of multi-faceted healthcare system management experience with at least five (5) years within a health plan setting.
  • 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 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.


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