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Quality Risk Management Director
2 months ago
We are seeking a highly skilled and experienced professional to lead our Quality Risk Management team. As a Regional Care Coordination Leader, you will be responsible for providing strategic leadership and direction to ensure the delivery of high-quality healthcare services in a cost-effective manner.
Key Responsibilities:- Develop and implement effective regional utilization management programs that support the delivery of high-quality healthcare services.
- Provide leadership and direction to ensure the smooth 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.
- 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, including NCQA, CMS, State, and 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.
- Minimum ten (10) years of multi-faceted health care system management experience with at least five (5) years within a health plan setting.
- Masters Degree required in Health Care Administration, Nursing, Business, or related field OR Bachelors degree in Health Care Administration, Nursing, Business, or related field.
