RN Director of Medical Management - Health Plan

Location: Atlanta, GA
Date Posted: 03-30-2018
RN Director of Medical Management (CM/UM/QM) - Managed Care
Atlanta, GA
Your Job Summary:
The Director of Medical Management (Case Management / Utilization Management / Quality Management) is responsible for strategically developing, coordinating, and implementing utilization management and case management initiatives within the health plan. This includes oversight of the day-to-day operations of the utilization management, case management, prior authorizations, and quality initiatives programs. The Director of Medical Management (CM/UM/QM) Provides ongoing maintenance and evaluation of systems and strategies to support the improvement of quality and utilization management accreditation through promoting and supporting innovation.  Develops, recommends and implements effective and efficient standards, protocols and processes, reports and benchmarks that support and further enhance utilization and quality management function and the quality of healthcare services.  Responsible for maintaining compliance with federal and state regulations as well as internal standards; facilitating assigned quality committees; and collecting, analyzing, and reporting data.

Your Reward:
This established, nationally-recognized organization is a Fortune 500 company that is committed to the health and happiness of all their staff. They offer a comprehensive benefits package to all full-time, permanent employees including low cost health insurance plan, dental, vision, and life insurance. To assist employees in living a healthier life, they offer either on-site fitness center or discounts to local fitness centers and a comprehensive wellness programs. They also offer free or reimbursed parking, tuition assistance, matching 401(k), employee stock purchase plan, generous PTO plus paid holidays, and much more!

Your Background: 

Valid, unrestricted state Registered Nurse (R.N.) license, and a Bachelor’s Degree in Nursing (BSN) or related field; Master’s degree is a plus.
Certified in Case Management (CCM) or Utilization Management (CPUM/CPUR) or Quality Management (CPHQ, ABQAURP) preferred.
Around 3-5 years’ clinical nursing experience in a high acuity setting.
Roughly 5-9 years’ experience in Care Coordination/Utilization Review/Quality Improvement for a Managed Care Organization (Health Plan, IPA, HMO, TPA, etc).
At least 7-8 years previous management experience, in roles of increasing responsibility, which included hiring and supervising nurses.
Project management experience in the planning, implementation, and controlling of medical projects.
Knowledge of various accreditation standards, such as NCQA or URAC, etc.
Familiar with claims payment rules and their impact on care management processes.
Knowledge of healthcare & insurance industry current and future trends, in order to assess future market needs.
Strong computer proficiency (MS Office) and typing skills are necessary. 
Skilled in influencing, leading and directing individuals in multiple functional areas.
Able to transform assignments from high-level objectives into independently established detailed goals.
Excellent verbal and written communication skills, as well as exceptional critical thinking skills.
Strong oral and written communication skills; ability to interact with internal and external contacts.
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
Your Duties:

Responsible for oversight of day to day operations of Case Management, Utilization Review, Quality Improvement, Care Transitions and Member Outreach.  Responsibility includes regulatory and accreditation compliance; oversight of Delegated Provider Groups and other health plan partnerships; oversight of utilization management/care management at vendor's related delegated functions; operations for direct lines of business and management services agreement functions, and interfacing with external agencies.  Ensures compliance with federal, state, and accreditation standards by developing, implementing and maintaining compliance processes within the department.  Responsible for ensuring compliance with National Committee for Quality Assurance (NCQA), URAC, or general accreditation.  Responds to State Audit requests, Rebid requirements, Contract questions, and RFPs.  Maintains audit readiness, by ongoing training, competency assessment, audit, monitoring of metrics and corrective action.  Promotes plan-wide understanding, communication, and coordination of UM/CM/QM programs.
Maintains highly effective staff by selecting, developing, and training employees; communicating job expectations and monitoring job results; counseling and coaching employees; and by initiating, coordinating, and enforcing systems, policies, and procedures.  Work collaboratively with key health care professionals toward identification of opportunities for improvement, trend analysis, education and development of appropriate action plans for problem resolution.  Ensure UM/CM/QM departmental policies and procedures are updated at least annually, new policies are developed as needed, and that all staff members are appropriately trained in updates.
Assists in developing the annual operating and capital budgets to sufficiently meet departmental needs and ensures that department stays within budget and accounts for variances.  Represents UM/CM/QM department by participating in assigned committees and interdisciplinary workgroups.  Prepares and distributes utilization and quality management reports for assigned committees indicating utilization and quality management patterns. Serves as resource for internal and external customers including Medical Directors and provider organizations.  Resolves issues by identifying the problem, examining solution options, implementing an action plan and providing resources.
410.983-9864 (CALL – TEXT – FAX)
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