Work for a purpose to help North Bay residents receive the highest quality care through multiple provider points. Our client has been voted “Best Place to Work” in the region cares about its’ patients and employees, thus providing a healthy, collaborative work environment in a beautiful setting. Excellent benefits in addition to medical, dental, 401k, include onsite wellness activities such as monthly chair massages, walking groups, yoga, fitness classes, mindful meditation and financial education.
In this role, you will:
Collaborate with the CMO and Medical Director to direct the Utilization Management department to take patient care and improved outcomes to a new level. Lead a team of eight RN’s and Care Coordinators in order to provide compliance with all health plan and government requirements and is responsible to ensure the organization passes all required audits, including HEDIS and NCQA. We are seeking a candidate that loves working with data, trends, and analytics to raise the bar throughout the entire care continuum.
“Own” this department and the important work that takes place: provide direction, design, implementation, and monitoring of utilization programs that exceed the organization’s utilization goals with customer satisfaction and improved patient outcomes as the guiding foundation. Use your skills with Six Sigma or other process workflow quality methods to create and use guidelines for patient referrals to Complex Care Management.
Be the “voice” of the UM/QA Committee – set monthly agenda, provide data and other information
Build relationships with partners such as health plans and through your team, provide an accurate interpretation of benefits and provide oversight for outside medical services based on Health Plan benefit guidelines and medical necessity
• RN required 3-5 years of current related leadership in Managed Care required.
• Experience in quality, discharge planning, utilization management, home care, and complex care management preferred.