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Quality Risk Management Director
2 months ago
As a key member of our team, you will provide strategic leadership for our regional utilization management program, ensuring the delivery of high-quality healthcare in the most appropriate and cost-effective manner. You will work closely with health plan and medical group utilization review activities to influence medical and clinical outcomes.
Key Responsibilities- Develop and implement effective regional utilization management strategies that support the delivery of high-quality healthcare.
- Collaborate with health plan and medical group leaders to ensure seamless integration of member care between hospitals, sub-acute, skilled nursing, ambulatory, and home care settings.
- Partner with regional and service area leadership to ensure that required internal systems and processes are in place to manage high-risk, high-cost care needs.
- Lead teams in complex systems, including change management efforts, and work in a highly matrixed system of care and decision-making.
- Develop 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, 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.
- Ensure the quality oversight of contracted and internal services in the continuum of care.
- Manage vendor relationships to ensure timely feedback and performance that meets service level agreements.
- 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 the operational efficiency of the Continuum to produce timely and accurate disposition of referrals for outpatient and post-acute services.
- In conjunction with TSPMG, establish and drive distinct workflows for pre-patriation and repatriation, deliberately directing members' care to and through KP-preferred network providers when clinically appropriate/reasonable.
- 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.
- 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.
- 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.
- Must be able to work in a Labor/Management Partnership environment.
- Clinical license such as RN preferred but not required.
- Another professional license desirable including but not limited to: Pharm D, NP, PA, JD, PhD, MD, EDS.
- Case management and utilization management experience.
