What are the responsibilities and job description for the Clinical Programs Quality/Utilization Director position at KP Recruiting Group?
KP Recruiting Group is a consulting firm that provides
leadership and exceptional talent to some of the world’s leading companies.
Headquartered in the Midwest, KP Recruiting Group has successfully completed
countless engagements in the United States, Europe and Latin America. We
represent clients in all industries and all sizes. Our mission is to provide
exceptional client and candidate experiences in order to get the best possible
results. On behalf of our client, we are excited to present the following confidential
role. We look forward to hearing from you and discussing the opportunity!
The Role:
- PROGRAM ACCOUNTABILITIES:
- Lead the quality and utilization management programs, all LOBs. This includes unique relationships held whereby quality and utilization is a delegated function to other delegated entities
- Assure that policies and operating procedures are comprehensive, implemented and reviewed annually
- Analyze and interpret data, assessing impact on care or service. Develop potential interventions and cost/benefit of such interventions. Prepare and present periodic reports on specific areas of health services utilization as directed. Report performance, both activity volume and outcome, on a monthly and year-to-date basis, assessing for improvement opportunities
- Prepare and present evidence of quality and utilization compliance for payer and regulatory audits and accreditation surveys
- Evaluate components of Clinical Programs Management; i.e. utilization management and quality management as appropriate to area of responsibility at least annually and assess for improvement opportunities
- Assist in external contracting for delegated services
- Research potential quality of care issues, assessing for system problems as well as individual, case specific issues
- Responsible for oversight of delegated quality programs
- Assist in the development, implementation, and maintenance of the provider reporting, which incorporates utilization, quality, and credentialing data. Collaborate with the credentialing and quality committees to ensure that provider performance monitoring is effectively handled
- Oversee the quality of care complaint handling process ensuring that it is timely and compliant with external requirements
- Develop action plans for health plan quality measurement programs, such as CMS 5 Star, NCQA commercial ratings, Marketplace Quality Rating System, and Health Share incentive measures
- Lead the quality and utilization management programs, all LOBs. This includes unique relationships held whereby quality and utilization is a delegated function to other delegated entities
Requirements
Master's Degree in Public Health, Healthcare Administration, Business Administration or relevant
Minimum 7 years Management experience including 7 years supervisory or leadership experience
Benefits
Our
client offers a comprehensive benefits package including:
401k
Matching
Family and
Individual Insurance Packages (Health, Life, Dental, and Vision)
Paid Time
Off & Paid Holidays
Long &
Short-Term Disability
Identity
Theft Plans
Retirement
& Pension Plans
Employee
Assistance Program
Employee
Referral Program
Tuition
Reimbursement Programs
Advancement
& Professional Growth opportunities
Parental
Leave
& More
