Quality Risk Management

4 weeks ago

Lithonia, United States HealthEcareers - Client Full time
Job Summary:
Provides regional leadership for joint Health Plan/TSPMG management efforts related to appropriate utilization of hospitals and specialty care, monitors transition of care, continuing care/sub-acute care resources, non-core hospital oversight to UM/case management, and manages referrals to maximize the quality and efficiency of care provided to our members. Oversight to repatriation process of bringing KP members to KP facilities and services when appropriate. Ensures that processes and systems are implemented for the patient to enter care at the optimal point in the care continuum and accesses appropriate levels of care with the goal of maximizing health status outcomes. Has a matrix relationship with TSPMG leaders and physicians to carry out the priorities defined by the health plan.
Essential Responsibilities:

  • Provides leadership in the development, direction and evaluation of an effective regional utilization management program that supports the delivery of high-quality health care in the most appropriate and cost-effective manner. Provides consultation and support for health plan and medical group utilization review activities that influence medical and clinical outcomes.
  • Provides 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 for example. Builds effective partnerships with other leaders and functions to ensure integration occurs. Represents the organization nonoperational relationships in partnership with other Continuum leaders as it pertains to hospitals, skilled nursing or rehab facilities, as well as with other network providers/practitioners.
  • Partners with regional and service area leadership as well as health care teams to ensure that required internal systems and processes to manage the high risk, high cost of care needs are delivered effectively and that they are supported, monitored and evaluated on an ongoing basis.
  • Leadership acumen directing teams in complex systems, including change management efforts. Ability to work in a highly matrixed system of care and decision making.
  • Develops systems to ensure effective coordination and integration between Utilization Management functions and Clinical Review, Contracting, and Claims Processes. Works collaboratively with other key TSPMG/Health Plan leaders to ensure that the processes exist that will result in benefits that are delivered and paid appropriately in accordance with contractual provisions and in the best interest of the patient.
  • Represents the region in utilization management in regulatory, licensing and legislative arenas, such as NCQA, CMS, State or other employer requirements. Prepares and presents information and testimony to ensure compliance with medical guidelines and procedures required by both KP internally and/or outside accredited agencies.
  • Provides leadership and direction for health plan integration with other agencies or 3rd party administrators who participate in utilization management for our members in delegated or non-delegated relationships, i.e. Harrington Health, PHOs, etc.
  • Accountable for the administrative leadership and budgetary responsibility for the team of staff that support these functions in the department. Ensures that their functions are aligned with and supportive of the overall operational leadership goals.
  • Ensures the quality oversight of contracted and internal services in the continuum of care.
  • Manages Vendor relationships such as those involving DME and transportation vendor to ensure timely feedback and performance that meets service level agreements.
  • Leads 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.
  • Ensures the operational efficiency of the Continuum to produce timely and accurate disposition of referrals for outpatient and post-acute services.
  • In conjunction with TSPMG, establishes and drives distinct workflows for pre-patriation and repatriation, deliberately directing members care to and through KP-preferred network providers when clinically appropriate/reasonable.
  • Provides leadership and direction in the identification, documentation and resolution of operational barriers that interfere with seamless care coordination to members.
  • Collaborates with member appeals.
  • Manages regulatory turn around for processing referrals and/or denials or appeals with relevant parties.
  • Participates and leads QRM involvement related to Tricare, Duals & related products.

Basic Qualifications:
Experience

  • Minimum ten (10) years of multi-faceted health care system management experience with at least five (5) years within a health plan setting.

Education

  • Masters Degree required in Health Care Administration, Nursing, Business or related field OR Bachelors degree in Health Care Administration, Nursing, Business or related field.

License, Certification, Registration

  • N/A

Additional 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 that demonstrate performance improvement and quality and service outcomes.
  • Must be able to work in a Labor/Management Partnership environment.

Preferred Qualifications:

  • Clinical license such as RN preferred but not required.
  • Another professional licenses desirable including but not limited to: Pharm D, NP, PA, JD, PhD, MD, EDS.
  • Case management and utilization management experience

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