Sr Director, Hospital & Continuing Care (RN)

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Atlanta, GA
$117,900 - $165,100
Job Type
Direct Hire
Bachelor, Licensed Practitioner, Master
Jun 19, 2017
Job ID
Sr Director, Hospital & Continuing Care

Job description
Provides regional leadership for joint Health Plan management efforts related to appropriate utilization of hospitals, transition of care, sub-acute care resources, hospital case management, and referrals to maximize the quality and efficiency of care provided to our members. 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 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 healthcare 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. Builds effective partnerships with other leaders and functions to ensure integration occurs. Represents the organization in operational relationships with 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, the high cost of care needs are delivered effectively and that they are supported, monitored and evaluated on an ongoing basis.
  • Assures development and implementation of hospital discharge management to ensure the effective, appropriate and integrated management of high risk, high cost and medically complex patients. Ensures the support, training, evaluation and reporting mechanisms are in place to meet local and national markets as well as employer groups and regulatory/ accrediting agencies needs and requirements.
  • Develops systems to ensure effective coordination and integration between Utilization Management functions and Clinical Review, Contracting, and Claims Processes. Works collaboratively with other key 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.
  • Provides leadership and consultation to physicians, service chiefs, other providers/practitioners and clinical personnel in the use of clinical measurement data for utilization management system improvements and redeployment of resources. Data will be used to review outcomes and continually improve health status outcomes.
  • Represents the region in utilization management in all 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 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. Health Plans, PHO's, etc.
  • Accountable for the administrative leadership and budgetary responsibility for the team of staff that supports 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.
Basic Qualifications:
  • Minimum eight years (8) of previous experience either in acute care or ambulatory environment required.
  • Minimum eight years (8) of management role experience in a health care setting with relevant experience in utilization management required.
  • Minimum five years (5) of Managed Care background and experience in increasingly complex health care management roles with relevant experience in utilization management required.
  • Master's degree required in health care administration, nursing, business or related clinical field OR a bachelor's degree with a minimum of six (6) years of directly related experience required.
License, Certification, Registration
  • N/A.
Additional Requirements:
  • Has experience with multiple sites of care, i.e. acute, ambulatory, home health, subacute, rehab, long term acute, hospice, palliative care or skilled nursing facilities.
  • Case Management experience.
Preferred Qualifications:
  • Clinical Professional Nurse or Nurse Practitioner background preferred.