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Kaiser Permanente Careers

Quality Assurance, UR & Case Management

Passion + Vision + Integrity = Excellence

Ensure consistency and the highest ethical standards across our entire organization. Our quality assurance team drives ongoing improvement by fostering an environment of support, providing technical and specialized consultative services, and inspiring ongoing excellence.

QRM Specialty Care Senior Manager

Location: Atlanta, GA Additional Locations:
Job Number: 771503 Date posted: 02/10/2019
Description:

Responsible for the oversight, direction and coordination of the QRM Non-core Inpatient Hospital and Rehab Reviewers, and Behavioral Health UM/ CM team and the Transplant/Transgender team. Also responsible for oversight of staff to ensure positive outcomes, improve performance, productivity and efficiency of the team and organizational operations through the provision of effective methods and strategies. Primary reasonability is ensuring team effectiveness and process optimization through their UM and case management duties.


Essential Responsibilities:

  • Direct oversight of the QRM Non-core Inpatient Hospital and Rehab Reviewers, Behavioral Health UM/ CM, Transplant and Transgender manager, supervisor and team members.

  • Provides management and oversight to this teams processes and policies in support of the organizations mission specifically support information flow, business process improvements and organizational planning and reporting.

  • Directs and manages operations to increase the effectiveness and efficiency of the specialty care review services which include behavioral health review activities.

  • Drive initiatives in the QRM management team and organizationally that contribute to long-term operational excellence.

  • Contribute to the short and long-term QRM organizational planning and strategy as part of the QRM Leadership team.

  • Assist the Sr. Director of QRM in long-term planning, including an initiative geared toward operational excellence.

  • Manage and coach Behavioral Health staff on a continuing basis.  

  • Works with QRM Compliance Manager to insure regulatory compliance for areas of accountability.

  • Remains knowledgeable of current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and areas of accountability. Educates staff and physicians on the changes and the implications of the changes. Ensures that policies and procedures are revised and implemented to meet requirements.

  • Assumes oversight and responsibility for his/her respective area as it relates to MDQR and NCQA site visit review preparation and coordination.

  • Provides the Sr. Director of QRM with monthly productivity and quality audits.

  • Determines staffing requirements for this area of QRM to ensure that services are rendered in the most effective and efficient manner.

  • Develops individual performance objectives for staff to ensure that competence of staff meets departmental standards.

  • Builds effective working relationships with physicians, hospital staff, vendors, and other departments within the health plan.

  • Interviews, hires, trains, disciplines, evaluate, counsels and terminate in conformance with EEO/AA goals, personnel policies, and organizational objectives.

  • Assists in the preparation and conduction of QRM staff meetings, in conjunction with the other QRM Leadership. Investigates, identifies and reports problems and inefficiencies in existing systems, and recommends changes when appropriate to the QRM Sr. Director.

  • Recommends to the QRM Sr. Director, revision of service area policies and procedures as needed.

  • Plans and participates in the orientation of newly contracted providers and facilities as requested; assists with contract maintenance of ancillary providers at the request of Represents the Georgia market in interregional activities when necessary/requested.

  • Works cross-functionally with other departments in striving to meet organizational goals and objectives. Participates in Marketing RFI/RFP process, information gathering, and group meetings as requested.

  • May perform other duties as assigned.

  • Basic Qualifications:

    Experience

  • Minimum eight (8) years of experience in clinical Behavioral Health experience required.

  • Minimum five (5) years of experience in management experience including managed care operations, program development, and outcome evaluation required.

  • Minimum five (5) years of experience in Utilization/Case Management required.

  • Education

  • Bachelor's degree in nursing with an unrestricted current RN licensure in the State of Georgia or Master's in Social Work.

  • License, Certification, Registration

  • Current licensure as a Registered Professional Nurse in the State of Georgia (in good standing) or able to obtain prior to date of hire or Valid Georgia state Social Work License (LMSW or LCSW).


  • Additional Requirements:

  • Experience with managed care systems, and proficiency in using various software, database, decision support techniques and computer applications including use of Microsoft Office products, preferred.


  • Preferred Qualifications:

  • Master's degree in nursing or master's degree in social work.
  • Primary Location: Georgia,Atlanta,Regional Office - 9 Piedmont 9 Piedmont Center 34 Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:00 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Salaried, Non-Union, Exempt Job Level: Manager with Direct Reports Job Category: QA / UR / Case Management Department: Utilization Management Travel: No Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    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 and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.

    About QA, Ur & Case Management Careers

    Careers In QA, Ur & Case Management

    As an organization, we are committed to delivering the same exemplary care no matter who you are, where you are, or what your needs. But how are those standards defined, measured, and assessed? That's where our quality assurance team comes in. Implementing the action plans and initiatives that will drive successful practices, you'll work across the organization to foster the necessary education, communication, and innovation that will enable us to operate as one KP — with our mission and goals in complete alignment.

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