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QA / UR / Case Management Jobs

Director, Patients Day Management - Atlanta

Location: Atlanta, Georgia;

Job ID : 3692171

Description

Responsible for optimizing quality of care and utilization management across KPGA inpatient and post-acute settings (Hospital, Skilled Nursing Facilities, Rehabilitation). Works in Partnership with: AMD, Hospital and Acute Care, VP, Quality, Research, and Resource Stewardship, Quality Resource Management Leaders, Senior Physician Director of IQM, other leaders/staff supporting continuum of care services, and national and inter-regional programs and colleagues. Also shares accountability for effectively managing to a growing multimillion dollar care continuum budget ($400M+).


Essential Responsibilities:
- Responsible for the efficient, effective, and appropriate delivery of all inpatient utilization
management services for KPGA members. Will provide direction to all staff regarding utilization review, care coordination, discharge planning, and other services across the continuum of care including collaboration with leaders responsible for vendor management.
- May initiates and develop new models of service to improve patient care experience and acute care utilization.
- Participates in the development, negotiation, and utilization of cost-effective, high quality local contracted and non-contracted outside hospital providers.
- Develops and implements quality and utilization standards for outside hospital and acute care to ensure coordinated plans of treatment, delivery of services that meet member needs, and the cost-effective utilization of necessary services.
- In conjunction with the stakeholders, develops strategies for determining the most cost-effective, efficient levels of continuing patient care clinically and operationally.
- Coordinates with TSPMG and HP colleagues to provide for the seamless transition of patients from the inpatient to outpatient settings.

- Collaborates in the development the annual PDR and SNF budgets.
- Participates and helps to inform and develop the annual outside hospital and care continuum budgets. Tracks and trends performance identifying improvement opportunities.

- Assures short and long-range financial goals are met by ensuing patients are cared for in outside facilities most effectively and efficiently.

- Monitors and if necessary develops performance dashboards to ensure that all care processes are performing optimally and if not creates interventions to remove variance.

- Demonstrates ability to lead and manage staff who are not direct reports.

- Demonstrates ability make system improvements applying process improvement science.

- Monitors and assesses trends, external environment and internal practices; makes recommendations to develop/adjust strategy to meet the changing business and market conditions.
- May facilitate utilization management education training.
- Analyzes & reports significant utilization trends, patterns, & impact to appropriate departmental & committees.
- Demonstrates high capability for written and verbal communications.

- Understands and adheres to Federal, State, TJC, NCQA, other regulatory agencies and internal standards and requirements.

- Serves as the resident expert on KP UM and Care Coordination programs and partners with leaders who have accountability for programs that prevent hospital admissions.

- Partners with Benefits Administration to resolve issues impacting unnecessary hospital or other facility length of stay.

- Experience directing/managing all services within the Care Continuum.

Qualifications: Basic Qualifications:
Experience
- Minimum five (5) years of experience in directing utilization management across the care continuum.
Education
- Bachelor's degree in BSN, Pharm D or MD or similar clincial licensed field.
License, Certification, Registration
- N/A.


Additional Requirements:
- Demonstrated interpersonal, negotiation, and management skills.
- Must be able to travel within and outside the state of Georgia.
- Strong communication, presentation, leadership, analytical and problem solving skills required.
- Ability to lead and manage through influence and change.
- Thorough knowledge of federal and state laws.


Preferred Qualifications:
- Master's degree in a related field such as nursing, business or health services administration preferred.



Primary Location:Georgia,Atlanta,Regional Office - 9 Piedmont 9 Piedmont Center 34

Scheduled Hours (1-40):40

Shift:Day

Working Days:Mon - Fri

Schedule:Full-time

Job Type:Standard

Employee Status:Regular

Employee Group:Salaried, Non-Union, Exempt

Job Level:Director/Senior Director

Job:QA / UR / Case Management

Public Department Name:Quality

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
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