Job Summary:
Responsible for the oversight, direction and coordination of the QRM Non-core Inpatient Hospital case managers; 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 and in partnership with the Emergency Care Management team the timely repatriation of KP members.
Essential Responsibilities:

Direct oversight of the QRM Non-core Inpatient Care Coordinators.

Provides management and oversight to this team 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.

Partners with the Emergency Care Management team to manage the timely repatriation of members in non-core facilities.

Works with QRM Compliance Manager to ensure 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 regulatory requirements 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.

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 five (5) years experience in clinical nursing experience required.

Minimum three (3) years experience in management experience including managed care operations, program development, and outcome evaluation required.

Minimum three (3) years experience in Utilization/Case Management required.

Education

Bachelors Degree in Nursing with an unrestricted current RN licensure in the State of Georgia.

License, Certification, Registration

Registered Professional Nurse License (Georgia)

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:

Masters degree in Nursing preferred.