Senior Director, Utilization Management/Case Management Outside Medical Services (RN preferred)
Atlanta, GeorgiaOur nurse leaders maintain a strong commitment to the highest standards of professional nursing practice and to sustain a culture of excellence. You will encourage your teams to use evidence-based practice to deliver high-quality patient care, contribute to research, and spread innovation beyond Kaiser Permanente. Backed by the resources of one of the nation’s largest health care providers, you’ll motivate and inspire your team to achieve goals, value individual contributions, and celebrate accomplishments in meaningful ways while realizing your own potential as a leader.
- Job Type: Full-time
- Job Level: Director/Senior Director
- Travel: No
Success Profile
We’re looking for Nurse Leaders who possess the following traits.
- Adaptable
- Collaborative
- Compassionate
- Leadership
- Problem-Solver
- Results-Oriented
Benefits
Our compensation and benefits are designed to help you and your family stay healthy and thrive.
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Medical, Vision & Dental
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Retirement Plans
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Tuition Reimbursement
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Tuition Reimbursement
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Supportive Team & Resources
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Career Growth & Development
Our Culture
Our Nurse Leaders cultivate an environment of compassion, integrity, trust, and open communication that helps our teams do their best work. Together, we pursue lifelong learning in the belief that it expands our knowledge so we can better serve our patients. We participate in research to inform our evidence-based care. Our nurses reflect the rich diversity of our members and communities, and provide culturally responsive and competent care that promotes the understanding of our members’ needs and preferences. At Kaiser Permanente, nurses are highly skilled professionals who exemplify leadership, critical thinking, and collaborative problem-solving, and deliver the right care, at the right time, in the right setting.
What Our People Are Saying
Ghada, PhD, RN, NEA-BC, CENP
SCAL Regional Director
Patient Care Services
“So proud to be a Kaiser Permanente nurse leader. Despite all the challenges we experienced with the pandemic, we remained true to our mission to provide safe, quality care to our patients and members, and continue to encourage our employees to grow and develop professionally. I have completed my Doctor of Philosophy in Nursing and lead with an exceptional team. There are boundless opportunities here.”
Gertrude, RN, BSN, MSA
Administrative Service Director
Nursing Administration
“Kaiser Permanente has a mission of providing affordable health care not just for our members, but also the community — which is a passion of mine. I consider myself very fortunate to work for an organization that values their employees. As a nurse leader, I LOVE what I do! We provide endless possibilities for growth and professional development.”
Michele, JD, MBA, RN
Director
Nursing Professional Development and
Simulation/Magnet Journey
“Kaiser Permanente provides its nurse leaders with opportunities to innovate and thrive in an evidence-based practice that’s advancing the science of nursing and embracing a culture of excellence.”
Philidah, MSN, RN
Sr. Director of Nursing
“It’s a privilege to work for Kaiser Permanente. They support nurses through a variety of learning opportunities, from self-paced learning to leadership courses and stretch assignments. It enables equitable opportunities for professional growth and career advancement.”
Mervin
Assistant Medical Center Administrator
“I’m incredibly grateful for the support I received from Kaiser Permanente. I would not be where I am right now without the mentoring from outstanding leaders, the strong relationships I built with my team, and the partnership with other departments.”
Melissa
Assistant Nurse Manager
“I’m in my first position here, but I’ve already had the opportunity to be part of the Magnet Journey, quality and safety committees, and co-chair Professional Nursing Excellence Council. Kaiser Permanente continues to help me grow through leadership training programs like Activate and stretch assignments.”
Aletha
Department Manager
“Kaiser Permanente has many resources and tools to help us grow professionally. We have courses and financial aid for individuals who choose to advance.I love being a leader because I love to encourage, inspire, and develop my team. I also embrace challenges and enjoy collaborating in projects that positively impact our members.”
Adriana
Department Manager RN
“Kaiser Permanente allows me to focus on preventive health care, which contrasts with my acute care background. I appreciate the preventive care services that we offer our members and the different forms of communication based on personal preference.”
Senior Director, Utilization Management/Case Management Outside Medical Services (RN preferred)
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Provides regional leadership for joint Health Plan/TSPMG management efforts related to appropriate utilization of hospitals and specialty care, monitors transition of care, continuing care/sub-acute care resources, non-core hospital oversight to UM/case management, and manages referrals to maximize the quality and efficiency of care provided to our members. Oversight to repatriation process of bringing KP members to KP facilities and services when appropriate. 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 TSPMG leaders and physicians to carry out the priorities defined by the health plan.
- Provides leadership in the development, direction and evaluation of an effective regional utilization management program that supports the delivery of high-quality health care 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 for example. Builds effective partnerships with other leaders and functions to ensure integration occurs. Represents the organization nonoperational relationships in partnership with other Continuum leaders as it pertains to 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, high cost of care needs are delivered effectively and that they are supported, monitored and evaluated on an ongoing basis.
- Leadership acumen directing teams in complex systems, including change management efforts. Ability to work in a highly matrixed system of care and decision making.
- Develops systems to ensure effective coordination and integration between Utilization Management functions and Clinical Review, Contracting, and Claims Processes. Works collaboratively with other key TSPMG/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.
- Represents the region in utilization management in 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 KP 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. Harrington Health, PHOs, etc.
- Accountable for the administrative leadership and budgetary responsibility for the team of staff that support 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.
- Manages Vendor relationships such as those involving DME and transportation vendor to ensure timely feedback and performance that meets service level agreements.
- Leads strategic thinking and planning on how best to structure the QRM/Referrals/Outside Services team and processes for optimal performance in meeting the needs of our members, physicians and organization at large.
- Ensures the operational efficiency of the Continuum to produce timely and accurate disposition of referrals for outpatient and post-acute services.
- In conjunction with TSPMG, establishes and drives distinct workflows for pre-patriation and repatriation, deliberately directing members care to and through KP-preferred network providers when clinically appropriate/reasonable.
- Provides leadership and direction in the identification, documentation and resolution of operational barriers that interfere with seamless care coordination to members.
- Collaborates with member appeals.
- Manages regulatory turn around for processing referrals and/or denials or appeals with relevant parties.
- Participates and leads QRM involvement related to Tricare, Duals & related products.
- Minimum ten (10) years of multi-faceted health care system management experience with at least five (5) years within a health plan setting.
- Masters Degree required in Health Care Administration, Nursing, Business or related field OR Bachelors degree in Health Care Administration, Nursing, Business or related field.
- N/A
- Thorough knowledge of quality assurance, quality improvement, utilization review, risk management, and accreditation and licensing requirements including NCQA, Knox-Keene Act, Federal HMO Act, CMS, HIPAA and related regulatory bodies.
- Track record achieving superior results that demonstrate performance improvement and quality and service outcomes.
- Must be able to work in a Labor/Management Partnership environment.
- Clinical license such as RN preferred but not required.
- Another professional licenses desirable including but not limited to: Pharm D, NP, PA, JD, PhD, MD, EDS.
- Case management and utilization management experience
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. Submit Interest
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