Nurse Executive Job Opportunities
Updated April 24, 2008

 

  • Director, Medical Management
    Washington, DC
Scope of Responsibility
Provides leadership and direction of the Medical Management Department, including the programs of Utilization Management, Care Coordination/Case Management, Disease Management, Grievance and Appeals and Quality Improvement.
 
Responsibilities
  • Manages a diverse staff of clinical and non-clinical personnel whose primary goal is to manage and promote quality healthcare for the members of the health plan.
  • Creates and manages the strategic plan for the department and ensures progress toward corporate goals and vision.
  • Creates and manages the budgets of the medical management department, including annual budget submission, monthly variance reporting, and adherence to approved budget.
  • Analyzes and monitors workflows and processes to ensure effective overall performance within the department and between other departments within the Plan.
  • Mentors management staff to strengthen managerial skills to provide leadership and coaching for mentoring their staff.
  • Collaborates with other senior leadership team members to support and implement strategic plans of the organization.
  • Provides leadership and direction for the daily operation of the Utilization Management/Authorizations Departments.
  • Responsible for designing and administering a program of Care Coordination for all enrollees integrating Case Management and Disease Management Program activities and supported by other departmental policies and procedures.
  • Participates in compliance and quality management efforts with a medical management focus to support the organization's accreditation, governmental and regulatory objectives.
  • Develops departmental documents including the Utilization Management (UM) Program Description, UM Workplan Evaluation, UM Workplan and Policies and Procedures.
  • Communicates, collaborates and assures cooperation with network and community physicians, hospital leaders, and other providers regarding health services and access to quality, cost effective health care services.
  • Interacts with and supports other department team members in initiatives that promote overall quality in members' healthcare and health services operational issues.
  • Monitors utilization frequency, quality and financial reports, by product line and aggregate, to identify changes in access patterns, trends or overall quality in healthcare of plan membership.
  • Monitors trends in UM and recommends changes in UM strategies to improve cost-effective, high-quality utilization.
  • Sponsors/leads projects that support strategic organizational initiatives. Participates on teams/committees as appropriate.
Knowledge, Skills and Abilities
  • Position requires outstanding oral, written communication skills, problem solving, and organizational and interper- sonal skills.
  • Requires leadership and management skills to lead and motivate a large diverse staff of clinical and non-clinical personnel. Also requires self-motivation, the ability to make independent, sound decisions, and to evaluate, plan, and implement change.
  • Strong project management skills and the ability to lead interdisciplinary teams.
  • Budget and financial planning skills required. Data analysis and interpretation skills, including the ability to understand and manage utilization, financial and operations data also required.
  • Registered nurse with current license.
  • CPHQ or CCM preferred
Education
  • Graduate of accredited school of nursing
  • Undergraduate degree in nursing or management required
  • Master's degree strongly preferred
  • Unrestricted nursing license in the District of Columbia
Work Background and Experience
  • Five (5) years clinical nursing experience
  • Five (5) years managed care experience required
  • Five (5) years of healthcare management experience at a supervisory or managerial level
  • Comprehensive knowledge of the care continuum, alternate environments of care, and the business aspects of risk contracting and health plan management
  • Working knowledge of government program regulations
  • Working knowledge of accreditation standards such as NCQA and URAC
For more information, contact David Mara at 804.527.1905.


 

The Scott & White Health Plan, located in Temple Texas, is looking for a dynamic individual to fill the position of Case Management Director. Voted the number one Health Plan in the State of Texas by U.S. News and World Report, the Scott & White Health Plan services over 220,000 members throughout the state of Texas. Additionally, the National Committee for Quality Assurance (NCQA) has accredited the SWHP with a status of “Excellent” for both commercial and Medicare products for the past four consecutive years.
 
Key Responsibilities:
Minimum Requirements
A Bachelor’s Degree, ( Master’s or equivalent preferred). Current licensed Registered Nurse in the state of Texas, (additional Case Management Certification preferred). Five to seven years experience.
 
If you feel you are a qualified candidate, please email your resume to:  kminnis@swmail.sw.org  You can also apply online at http://jobs.sw.org
 
Scott & White is an equal opportunity employer.

 

 

The Scott & White Health Plan, located in Temple Texas, is looking for a dynamic individual to fill the position of Utilization Management Director. Voted the number one Health Plan in the State of Texas by U.S. News and World Report, the Scott & White Health Plan services over 220,000 members throughout the state of Texas. Additionally, the National Committee for Quality Assurance (NCQA) has accredited the SWHP with a status of “Excellent” for both commercial and Medicare products for the past four consecutive years.
 
Key Responsibilities:
Minimum Requirements:
A Bachelor’s Degree, ( Master’s or equivalent preferred). Licensed Registered Nurse with current unrestricted Texas license. Five to seven years experience.
 
If you feel you are a qualified candidate, please email your resume to:  kminnis@swmail.sw.org  You can also apply online at http://jobs.sw.org
 
Scott & White is an equal opportunity employer.

 

 

  • Director Health Care Management Services - Disease Management
    Virginia Beach, VA
Job Summary
The Director, Health Care Management Services is responsible for the development, implementation and coordination of a comprehensive health care program that will assist Health Care Management Services, Medical Management, and/or Health Plans, resulting in improved health outcomes for members.
 
Primary Responsibilities
  • Assists in development and implementation of clinical programs in accordance with the goals of the health plan's mission, vision and values, the needs of the health plans, federal and state regulatory requirements and NCQA standards.
  • Serves as a clinical leader to HCMS/Medical Management associates.
  • Manages and evaluates team’s performance and ensures adherence to department’s standards.
  • Provides departments with updates as needed to ensure continued compliance with specific medical management standards.
  • Assists in the development of medical management policy, procedures and guidelines that relate to specific programs.
  • Assists in evaluating and implementing contracts in coordination with Network Development as needed to implement specific programs.
  • Assists Member Services and Provider Inquiry Department with timely response to issues including complaint resolution.
  • Assists in developing clinical management guidelines including:
  • Conducting literature search to identify "evidenced-based" management.
  • Identifying changes in practice which may require updating of guidelines.
  • Developing DRAFT guidelines as directed.
  • Identifying national providers experienced in treating patients within these areas.
  • Coordinating physician advisory groups.
  • Assists in managing the information requirements of HCMS/Medical Management programs.
  • Acquires data and evaluates necessary medical, mental health and substance abuse services for cost containment.
  • Identification and implementation of HCMS/Medical Management "best practices."
  • Ensures that delegated medical management activities are contracted, reviewed and reported according to estab- lished criteria.
  • Evaluates programs quarterly.
  • Supports and participates in quality initiatives and activities including clinical indicators reporting, focus studies and HEDIS reporting.
  • Ensures compliance with state reporting on utilization management activities for accuracy.
  • May assist in developing the annual operating and capital budgets to sufficiently meet departmental needs.
Education
Required: Bachelors Degree, or equivalent work experience
Preferred: MSN, MPH, MPA, or MSW or related or MBA with Health Care Concentration
 
Required
  • Must have five years management experience.
  • Must have at least five years of current experience in utilization management in a managed care setting.
Knowledge and Technical Skills
Required:
  • Demonstrated medical management experience in health care.
  • Knowledge of Utilization Management targets.
  • Self-directed with strong organizational skills.
  • Excellent verbal and written communication skills.
  • Ability to foster inter and intradepartmental communication and team building.
  • Strong analytical capabilities.
  • Attention to detail.
  • Mastery of computer software.
  • Statistical reporting experience preferred.
  • Multi-task oriented with ability to follow-up on numerous complex problems.
  • Strong customer focus.
Certifications or Licensure
Required: RN or LCSW , LPC
Preferred: Certified Case Manager
 
For more information, please call David Mara at 804.527.1905.

 



 

Brief Description of Duties
Minimum Qualifications or Equivalents
Preferred Qualifications
Prior experience in managed care specifically in utilization, medical review, or case management areas.
 
For more information, please call David Mara at 804.527.1905.
 


 

Brief Description of Duties
The manager will oversee the functions of the case management department. The manager ensures compliance with nationally recognized accreditation and governmental standards, as well as, compliance with case management standards. In addition, will oversee committees for case management to ensure that policies and procedures are developed and are in alignment with the standards and regulatory bodies and the core components of the case management process are followed; that quality assurance is conducted regularly to ensure compliance to policies and procedures and standards’ and to ensure that case managers are educated in accreditation standards, the case management process, concepts and standards.
Minimum Qualifications or Equivalents
For more information please contact David Mara at 804.527.1905.
 


 

Make it yours. At Kaiser Permanente, we realize that it takes more than expert medical care to be the nation’s leading nonprofit integrated health plan. It takes advanced technologies, state-of-the-art facilities, and the people to support them. Come impact your future, and the future of care. Join us in Oakland, California.
 
State Programs Clinical Consultant
 
This individual will act as a clinical consultant and content expert for complex functional areas comprising the continuum of clinical services provided under Kaiser Permanente’s Medi-Cal and state program agreements. Specific tasks include coordinating health plan audits; providing medical and state programs expertise to regional, local, and statewide operations to ensure compliance; and answering questions regarding utilization review, quality review, links and carved out services, appeals and grievances, and case management. In this position, you will also work with Kaiser Permanente departments and senior leadership at divisional, regional, and local levels as consultant on Department of Managed Health Care compliance issues on existing and planned operations. In addition, you will participate in the ongoing development and implementation of education programs about Medi-Cal and state program clinical-related business and regulatory requirements.
 
A bachelor's degree in business administration, health care administration, public health administration, or other related field is required; a master’s degree is strongly preferred. A current California Registered Nurse license, five years of clinical RN experience, and five years’ experience in interpreting and managing Medi-Cal, Medicare, Title 22, and other government program requirements are also required. You must also have the ability to manage multiple projects and use excellent analytical skills on highly complex, politically sensitive projects by identifying key business issues, and develop action plans recognizing differing and competing multidisciplinary perspectives. In addition, strong collaboration and communication skills working with key clients and senior leadership are essential. Health care operations, managed care, health care insurance, health care compliance, and consulting experience preferred. Knowledge of Kaiser Permanente and state program regulations, demonstrated contract negotiation experience, and working knowledge of regulatory state program environment highly preferred.
 
We offer a highly competitive salary and an exceptional benefits package. For immediate consideration, please e-mail your resume to jermaine.b.jenkins@kp.org. Please reference Source Code SPCC031808CAHQ when responding. Please visit jobs.kp.org for complete qualifications and job submission details, referencing job number RE.0800240. Principals only. Kaiser Permanente is an EOE/AA employer.
 
This position supports Kaiser Permanente’s code of conduct and compliance by adhering to all laws and regulations, accreditation and licensure requirements, and internal policies and procedures.
 
jobs.kp.org
 
KAISER PERMANENTE
 

 
 

Description
This behaviorial health company is a multi-line managed care organization that provides Medicaid-related programs to organizations and individuals through government subsidized programs. We have an excellent opportunity for a Manager of Provider Relations and Contracting. This position will implement development activities for the recruitment, contracting and retention of providers. Negotiate contracts and develop strategies and methodologies for specific network development initiatives.
 
Position Responsibilities Include:
Qualifications
For additional information, please contact David Mara at 804.527.1905.
 


 

Experience with PPO Network providers
Strong relationship building skills
Contract experience
Strategic thinker
 
Responsibilities
Provide strategic leadership to the implementation of medical network, medical provider and medical vendor contracting strategies for assigned region.
 
Qualifications
Bachelor's degree or equivalent plus 8-10 years related work experience required.  ICA - International Claim Association (ICA), Fellow, Life Management Institute - LOMA (FLMI), Health Insurance Association of America (HIAA), or Academy for Healthcare Management (AHM) designations preferred.  Advanced knowledge of business unit products and basic knowledge of company products required.  Must have excellent planning/organizational, problem-solving, analytical, presentation, and oral and written communication skills, as well as advanced math skills.  Excellent leadership skills required, along with excellent time management and decision-making skills.  Must be able to maintain a high degree of accuracy.  Advanced computer skills and knowledge of business unit applications required.  Ability to maintain confidentiality essential.  Travel required 30% including overnight stays.
 
For additional information, please contact David Mara at 804.527.1905.
 


 

Aetna, a leading provider of healthcare and related group benefits is seeking a Senior Clinical Director to oversee their office in High Point, NC. This senior nursing executive will have an opportunity to hire a staff of high performing professionals to address the member’s needs across the continuum of care.
Requirements
If you might be interested in learning more about this position I would welcome an opportunity to speak with you.
 
Carrie Hackett
Managing Partner
Grant Cooper & Associates
800-886-4690 X 121
hackett@grantcooper.com

 

 

Job Summary
Serves as the liaison and advocate for members in support of the Synergy Personal Health Management Program.  Provides education, assessment and outreach to high risk and/or non-compliant members with chronic diseases to encourage participation in the Synergy program.  Serves as the direct interface with network practitioners, providing outreach, education, and clinical guidance on program strategies. Works closely with Client clinical departments to ensure collaboration between the Health Plan and the Synergy program staff.
 
Minimum Qualifications

Education
Bachelor’s Degree in a health related field.  Master’s Degree preferred, such as MSW, MPH, MHA, MSN, etc.  Licensure as a health professional desirable.
 
Experience
Minimum of three years experience in a health care delivery environment, managed care plan, or Disease Management provider. Experience as a consumer or family advocate, either in volunteer or paid settings, with knowledge of Medicaid and Medicare regulations/standards preferred.
 
Knowledge/Skills
Accountabilities
 
Job Performance/Responsibilities
Please direct all inquires to Dave Mara at 804.527.1905 or email him at dmara@namcp.org


 

  • Director, Seattle Synergy Operations
    Seattle, WA
Job Summary
The Director, Seattle Synergy Operations directs and oversees the operations for the Seattle Call Center. The Director of Seattle Synergy Operations is a full time position that provides day-to-day professional, technical and managerial support to the Seattle Synergy clinical and non-clinical staff to ensure compliance with program policies and procedures, industry standards and regulatory requirements. This individual will be responsible for the integration and coordination of Care Coaching Program services for clients serviced out of the Seattle Call Center. The Director works closely with the technical support staff, managerial staff, and other clinical departments in Tampa and Seattle to ensure quality service delivery. This individual will serve as a liaison between care coaching staff, providers, patients and health plans/clients.
 
Minimum Qualifications
 
Education
Minimum of a bachelor’s degree in a health care field. Masters preferred.
 
Licensure
Active, unrestricted RN or other health care licensure required.
 
Experience
Minimum of 5 years of demonstrated Call center and/or Managed Care leadership experience at a manager/director level required, with specific experience in Disease Management or Case Management preferred.
 
Knowledge
  • Demonstrated in-depth knowledge of call center management.
  • Demonstrated in-depth knowledge of Disease Management and Case Management principles.
  • Excellent communication skills, both verbal and written.
  • Ability to direct and coordinate programs, projects, resources, and staff across multiple company departments and locations.
  • Ability to analyze telephone statistics and other program data to set and monitor goals; implement corrective strategies to improve effectiveness and efficiency; and identify opportunities for program improvements.
  • Working knowledge of government sponsored programs (Medicare, Medicaid, etc) and regulations surrounding these programs.
  • Demonstrated leadership abilities in a clinical operations environment.
  • Ability to communicate effectively with a wide range of individuals, both internal and external.
  • Must be able to work independently, while coordinating operational processes with the Tampa operation.
  • Excellent computer skills, including use of Microsoft Office Suite and other office productivity software, and disease management applications.
  • In-depth knowledge of managed care operations, including benefit design and UM/CM techniques.
Accountabilities
 
Job Performance/Responsibilities
 
General Duties
  • Management of the Seattle Synergy operations staff and the Seattle call center.
  • Provides the day-to-day professional and technical support to the Synergy staff to ensure efficient operation of the department; including compliance with policies and procedures, contractual obligations and regulatory requirements.
  • Assures that all regulatory and accreditation standards are implemented and met.
  • Assures that Policies & Procedures, Operational Guidelines, and process workflows are implemented and adhered to by staff.
  • Analyzes Seattle call center data to ensure effectiveness, quality, productivity, and profitability standards are met.
  • Assures staffing is optimized to effectively and efficiently deliver Synergy services to members and clients.
  • Develops and implements work flows and policies and procedures that accurately document the Synergy operation.
  • Provides input into existing reports and provides suggestions for enhancement.
  • Manages the budget associated with the Seattle operation.
  • Interviews and hires staff and supervisors for the Synergy Seattle operation.
  • Participates with the sales team in delivering prospective client presentations about the Synergy program.
  • Actively interacts and collaborates with clients regarding the Synergy program; participates in client presentations and account meetings.
  • Assists in the licensing and accreditation process for all programs.
  • Assists the Vice-President in plans for growth.
  • Provides input and direction to Information Services on systems issues and enhancements.
  • Offers input and assistance with development of education and training programs.
  • Assures delivery expectations of client contracts are being met.
  • Provides required reports and special projects as needed.
  • Provides input to the Vice President and Executive Vice President regarding program enhancements and operational improvements.
  • Assists in the annual review of the Program Description; provides input into the annual program evaluation and the program work plan.
Please direct all inquires to Dave Mara at 804.527.1905 or email him at dmara@namcp.org
 


 

Job Summary
The Senior Vice President of Quality Improvement, Training and Regulatory Affairs is responsible for the development and implementation of corporate Quality Improvement initiatives, Education and Training programs, Corporate Compliance  and directives as well as the oversight of accreditation standards .
 
Minimum Qualifications 
 
Education
RN degree level health care clinician.  Additional certification in specialty fields or other advanced certification preferred. 
 
Experience
8-10 years experience in Quality Improvement. Five years Director level management experience specifically in Quality Improvement/Management. Working knowledge of NCQA and URAC accreditation standards and direct experience with and responsibility for NCQA and URAC surveys. Experience in both the health plan environment as well as in a health plan vendor organization environment. 
 
Knowledge/Skills
Accountabilities
Customer Services-Internal
Customer Service-External
Please direct all inquires to Dave Mara at 804.527.1905 or email him at dmara@namcp.org
 


 

  • Director, Accreditation and Delegation Oversight
    Baltimore, MD
Position Summary
The Director of Accreditation and Delegation Oversight is responsible for creating a strategy that will promote success in achieving the organization’s goals for accreditation in designated markets. This position provides project management of accreditation and external quality review activities as well as develops and maintains a delegation oversight program and ensures oversight occurs in accordance with CMS and NCQA standards. Excellent communication skills required, both written and oral, to internal and external stakeholders. The ability to establish and maintain effective working relationships with State, CMS and accreditation organizations is essential. Responsibilities also include compiling and completing reports for quality improvement and provider advisory committees.
 
Essential Duties and Responsibilities
  • Complete and maintain a crosswalk between CMS, NCQA and state regulations related to quality.
  • Standardize related processes, policies and procedures and standard operating procedures.
  • Refine Delegation Oversight Program and tools.
  • Ensure that all delegated activities are reviewed on a regular basis according to applicable NCQA, CMS and state standards and plans of correction are tracked and outstanding issues addressed in a timely manner.
  • Develop policies and procedures and standard operating procedures as needed.
  • Collaborate with departments to address gaps and open tasks.
  • Identify training needs of staff and resources related to NCQA and other quality standards. Facilitate training in these areas.
  • Coach staff on standards and documentation to demonstrate compliance.
  • Create status reports and present to Quality Improvement Committee and other meetings.
  • Create reports for state Medicaid programs, CMS, EQRO and NCQA organizations
  • Assist and support VP, Quality as required.
Qualifications
  • Knowledge of NCQA and government standards and participation in an NCQA review is required.
  • Experience in quality improvement in a managed care setting required.
  • Experience as a leader in complex or system-wide project management required.
  • Professional attitude and team player, with ability to work independently.
  • Experience coaching and mentoring staff.
  • Excellent phone/communication skills.
  • Ability to comprehend technical documents.
  • Multiple task oriented.
  • Flexible with the ability to shift priorities on short notice.
Education and/or Experience
  • Bachelor’s Degree, Health Care preferred
  • Three years experience leading accreditation activities
  • Familiarity with project management process and tools
For additional information, please contact David Mara at 804.527.1905 or email your resume to dmara@namcp.org
 


 

Summary
 
The Manager of Clinical Training will lead a multi-discipline training and development function for clinical and clinical support staff.  The Manager of Training will design and implement clinical training programs for employees across the health plan's business units who work in facility-based settings as well as at home throughout the country.   This position is primarily responsible for ensuring that clinical and clinical support staff have the knowledge and skills required to deliver the health plan's clinical programs in accordance with performance standards. Periodic travel to worksites in Maryland, Ohio, and Georgia is required.
 
Qualifications
Responsibilities
Knowledge, Skills and Abilities
For additional information, please contact David Mara at 804.527.1905 or email your resume to dmara@namcp.org
 


 

Health Net, Inc. (NYSE: HNT) is among the nation’s largest publicly traded managed health care companies. Health Net’s mission is to help people be healthy, secure and comfortable. The company’s POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals. For more information on Health Net, Inc., please visit the company’s Web site at www.healthnet.com
 
Job Summary
The Director, Clinical Accounts is responsible for region activities related to process improvement and project implementation of the clinical account management program. A strong focus is placed on identified groups, including planning, development, implementation, and monitoring of population programs for the identified population.
 
Essential Duties and Responsibilities
Requirements
 
Education
Bachelor’s Degree
 
Certification/License
Current RN Professional Licensure
 
Experience
Knowledge, Skills & Abilities
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
 
For immediate consideration, visit: WWW.CAREERSATHEALTHNET.COM, locate this position by Job Number 08000377, scroll down, click ob job title and apply online.
 
Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening. Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.

  • Associate Vice President, Health Care Management Services
    Austin, Texas
Job Summary
The Associate Vice President Health Care Management Services manages the utilization/care management process ensuring the delivery of essential services that effectively address the total healthcare needs of the health plan’s members.
 
Primary Responsibilities
  • Implements and manages health care management, utilization, cost, and quality objectives in accordance with the goals of the health plan’s mission, vision and values, the needs of the health plans, federal and state regulatory requirements and NCQA standards.
  • Collaborates with the peers to ensure a seamless interface between HCMS and Medical Management.
  • Identifies opportunities to improve the customer service and quality outcomes for our members.
  • Collaborates with peers to initiate innovative health care pilots to improve the overall HCMS/medical management program.
  • Interfaces with other departments to ensure the complete integration of behavioral health and physical health.
  • Overseas the development of medical management policies, procedures, and guidelines.
  • Ensures implementation and continued compliance by providing updates on specific medical management standards to Directors and staff.
  • Assists in developing clinical management guidelines including: Conducting literature search to identify "evidenced- based" management. Identifying changes in practice which may require updating of guidelines. Developing DRAFT guidelines as directed. Identifying national providers experienced in treating patients. Coordinating physician advisory groups.
  • Ensures that delegated medical management activities are contracted, reviewed and reported according to estab- lished criteria.
  • Evaluates programs quarterly.
  • Supports and participates in quality initiatives and activities including clinical indicators reporting, focus studies and HEDIS reporting.
  • Ensures compliance with state reporting on utilization management activities for accuracy. • May develop the annual operating and capital budgets to sufficiently meet departmental needs.
Education and Experience
Required
  • Bachelors Degree in a health care field
Preferred
  • Masters Degree in a health care field
  • MSN, MPH, MPA, or MSW or related or MBA with Health Care concentration
Years and Type of Experience
Required
  • Must have three years post Masters clinical experience.
  • Must have at least five years of current experience in utilization management in a managed care setting.
  • Must have 3 years of management experience.
Knowledge and Technical Skills
Required
  • Industry and clinical knowledge - Possesses a comprehensive knowledge of managed care, best practices, and issues related to coordinating behavioral and physical health.
  • Leadership - Sets a clear direction for health care. Balances marketplace requirements with the objectives of the health plan's health program. Able to manage indirect reporting relationships.
  • Management of resources - Manages human resources to optimal performance. Efficiently manages projects to a timely completion. Identifies gaps and proposes solutions. Able to develop and manage budgets.
  • Communication skills - Strong verbal and written communication skills. Able to negotiate with a variety of stakehold- ers. Capable of networking with internal resources as well as external partners and constituents.
  • Computer skills - Possesses a working knowledge of Microsoft Office and the Internet. Interested in developing higher-level computer skills.Certifications or Licensure
Preferred
  • RN
  • LCSW, LPC
  • Certified Case Manager
For more information, please contact David Mara at 804.527.1905.

  • Director, Acccreditation and Delegation Oversight
    Baltimore, MD
The Director of Accreditation and Delegation Oversight is responsible for creating a strategy that will promote success in achieving the organization’s goals for accreditation in designated markets. This position provides project management of accreditation and external quality review activities as well as develops and maintains a delegation oversight program and ensures oversight occurs in accordance with CMS and NCQA standards. Excellent communication skills required, both written and oral, to internal and external stakeholders. The ability to establish and maintain effective working relationships with State, CMS and accreditation organizations is essential. Responsibilities also include compiling and completing reports for quality improvement and provider advisory committees.
 
Essential Duties and Responsibilities
  • Complete and maintain a crosswalk between CMS, NCQA and state regulations related to quality.
  • Standardize related processes, policies and procedures and standard operating procedures.
  • Refine Delegation Oversight Program and tools.
  • Ensure that all delegated activities are reviewed on a regular basis according to applicable NCQA, CMS and state standards and plans of correction are tracked and outstanding issues addressed in a timely manner.
  • Develop policies and procedures and standard operating procedures as needed.
  • Collaborate with departments to address gaps and open tasks.
  • Identify training needs of staff and resources related to NCQA and other quality standards. Facilitate training in these areas.
  • Coach staff on standards and documentation to demonstrate compliance.
  • Create status reports and present to Quality Improvement Committee and other meetings.
  • Create reports for state Medicaid programs, CMS, EQRO and NCQA organizations.
  • Assist and support VP, Quality as required.
Qualifications
  • Knowledge of NCQA and government standards and participation in an NCQA review is required.
  • Experience in quality improvement in a managed care setting required.
  • Experience as a leader in complex or system-wide project management required.
  • Professional attitude and team player, with ability to work independently.
  • Experience coaching and mentoring staff.
  • Excellent phone/communication skills.
  • Ability to comprehend technical documents.
  • Multiple task oriented
  • Flexible with the ability to shift priorities on short notice.
Education and Experience
  • Bachelor’s Degree, Health Care preferred.
  • 3 years experience leading accreditation activities.
  • Familiarity with project management process and tools.
Please direct all inquiries to Dave Mara at 804.527.1905 or email him at dmara@namcp.org
 
  • Director, Medical Management
    Magellan Health Services
    Phoenix, AZ
This Director position maintains accountability for all Clinical Review functions and efficiency of clinical review processes. Maintains and supports UM compliance, including customer compliance, due diligence, as well as URAC, NCQA and other applicable standards. Provides support and communication for external clients in areas of medical management and clinical review.
 
Responsibilities/Duties
  • Works closely with Vice President of Clinical Operations to provide NCQA and URAC guidance and oversight for the clinical review process.
  • Maintains oversight for the success and completeness of the Quality Management and Utilization Management Programs for Clinical Operations.
  • Continuously provides feedback and suggestions for improvement of Informa.
  • Directs, coordinates and evaluates efficiency and productivity of the initial clinical reviewer functions, and appeal process.
  • Responsible for resolution and communication of medical management issues, client maintenance, concerns and corrective action plan activities and reporting.
  • Acts on an ad hoc basis as Clinical Implementation Specialist working with the Network Operations, Provider Services Group, and Client Integration Team, supporting medical management process.
  • Member of Utilization Management Committee.
Knowledge, Skills & Abilities
  • Thorough understanding of health care financing and payment systems.
  • Excellent quantitative and analytical skills.
  • Excellent verbal, written, and communication skills.
  • Customer oriented with excellent interpersonal skills and strong commitment to quality patient care.
Education & Experience
  • Current Arizona Registered Nurse with active license.
  • Baccalaureate degree required or equivalent experience.
  • Masters degree preferred.
  • A minimum of ten (10) years experience in healthcare management.
  • At least five (5) years experience in a managed care environment.
  • At least five (5) years experience in a management level in Utilization and Quality Management.
Please conact Terri Holub, Sr. Sourcing & Research Recruiter at Magellan Health Services, Inc.
www.magellanhealth.com
(888) 899-7803 ex. 65162
(916) 852-2643 fax
tmholub@magellanhealth.com

  • Manager, Quality Outcomes
    Baltimore, MD
Position Summary
The Manager of Quality Outcomes coordinates the operational components of the Quality Improvement process on a daily basis, meeting state and federal regulatory requirements and the expectations of providers and members.
 
Essential Duties and Responsibilities
  • Educates staff on the principles of quality improvement and acts as a staff resource for quality improvement questions.
  • Investigates quality of care issues for all regions, maintain a database, produce quarterly reports to credentialing, the QIC and Board of Directors.
  • Oversees the QAPI projects to improve services to members.
  • Participates in NQIP HEDIS data collection and monthly provider specific reports.
  • Oversees the member (CAHPS) and provider satisfaction surveys, analyzes results and reports to committees.
  • Revises and develops policies and procedures and standard operating procedures related to quality as needed.
  • Sets agenda and coordinates QIC meetings.
  • Researches and develops preventive health and other clinical guidelines with the Senior Medical Director.
  • Coordinates the development of the Corporate QI Work Plan and Annual Corporate QI Evaluation with all department heads.
  • Oversees risk management/quality of care issues tracking and analysis
  • Maintains quality improvement issues documentation and tracking reports.
  • Assists other departments in monitoring delegated functions
  • Monitors quality indicators and data analysis and reports results to committees.
  • Monitors and supports the complaints and grievance analysis.
  • Conducts audits on inter-rater reliability.
  • Supports Member Services and Provider Network with member and provider education materials.
  • Other duties as required.
Minimum Qualifications
  • Bachelor’s Degree in related field
  • A minimum of 5 years of clinical experience in health care
  • A minimum of 3 years of supervisory experience; prior QI experience in a managed care setting preferred.
  • At least 3 years recent experience participating in a leadership role in NCQA accreditation activities.
Certification/Licensure
Registered Nurse (RN) with current license in the State.
 
Knowledge, Skills and Abilities
  • Ability to adapt and respond to complex, fast paced, rapid growth/results oriented environment.
  • Ability to simultaneously lead and manage multiple high priority projects and responsibilities.
  • Ability to analyze and evaluate data and problems, develop alternative solutions, and identify trends and patterns.
  • Excellent communication and presentation skills and the ability to interact with all levels of management, as well as key state and federal regulatory agencies.
  • Ability to positively interact with other clinicians, senior management, patients and their families, and all levels of medical and non-medical professionals.
Confidentiality
This position is exposed to patient medical record information that revealed if inappropriately would be against company policy, professional ethics and integrity.
 
Physical Demands/Work Environment
Must be able to work long hours to meet critical deadlines.
 
For a more detailed job description or additional information, please contact David Mara at 804.527.1905 or email your resume to dmara@namcp.org
 

Primary Function
Responsible for development and operational oversight and day-to-day management of all actrivities associated with the Chronic Care Improvement Program (case and disease management), inpatient/UM management (onsite inpatient) and Social Services.
 
Responsibilities
Serves as point person for Health Services for all CCIP Programs.
Oversees Health Risk Assessment, CM, DM, SS and Life Enhancement program and staff.
Coordinates and oversees all Disease Management and Intensive CM.
Develops disease management programs to ensure compliance with all regulatory agencies, e.g.: HIPAA, CMS, URAC, NCQA, DOI/DOL etc.
Implements and maintains all CCIP management reports.
Evaluates and trends data with a focus on strategic planning.
Works with all plan Depts. in promoting CCIP management programs.
Assists with development of new systems related to areas of responsibility.
Oversees and develops new programs.
Performs other duties as assigned.

Supervisory Responsibilities
Direct management responsibilities for DM, CM, IP, SS and LEP.

Job Related Skills
Is a registered nurse in TN with extensive background in leadership.
Has strategic planning and program development skills.
Is able to communicate information accurately and timely.
Has the ability to articulate information at all levels of understanding.
Has strong healthcare analytical/problem solving skills.
Has the ability to analyze data and identify trends and opportunities for improvement.
Has the ability to handle multiple tasks, set priorities and develop action items.
Is detail oriented.
Is skilled in the diplomatic, educational approach along with team-building skills.

Experience
RN with five plus years of experiendce in managed care or healthcare .
Experience or in-depth knowledge with a proven record of disease management programs including outcomes programs and their implementation.
Minimum of 5 years experience in management.
Experience and knowledge of regulatory agency requirements.

Please direct all inquiries to Dave Mara at 804.527.1905 or email him at dmara@namcp.org
 

  • Concurrent Review RN - Join an industry leader
AmeriChoice, a UnitedHealth Group company, is a recognized leader and innovator in providing managed health care solutions to its membership, which includes Medicaid, Medicare and SCHIP recipients.  With over a decade of growth and success, we are poised for continued expansion of our services in this dynamic marketplace. Our commitment to this specialized market makes a genuine difference in the lives of our 1.4 million members. Join us, do rewarding work, and build a great career.
 
Are you looking for a change from direct patient care but still want to use your clinical knowledge to help patients receive excellent medical care?  If so, this could be the perfect position for you! Corporate growth has created a need for us to hire a new Concurrent Review Nurse to address utilization management in the Arizona market. The chosen candidate would work with patients and medical providers to determine the appropriateness of various types of medical care. After the candidate has successfully and continually met performance expectations, he/she may have the opportunity to work for home.
 
Key responsibilities include:
  • Using Milliman and Robertson (M&R) criteria to evaluate appropriateness of care
  • Performing on-site and telephonic concurrent reviews
  • Maintaining ongoing contact with physicians to obtain accurate patient data and clarify diagnoses
  • Communicating care decisions to physicians and case managers
  • Helping to develop the Concurrent Review Orientation Program
Only RNs with current and valid licensure in Arizona and clinical experience will be considered for this position. A background in hospital-based utilization management or home care concurrent review is preferred; field-based work is a plus. Basic computer proficiency is also necessary. If you meet these criteria, and you are an independent thinker who also works well with other professionals, consider applying for this promising position.
 
UnitedHealth Group offers a full range of comprehensive benefits, including medical, dental and vision, as well as a matching 401k and an employee stock purchase plan.
 
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V.
 
Apply now by visiting http://www/unitedhealthgroup.com/careers/index.htm and type the following requisition number into the search block: 192123
 

  • Project Managers (07-158)
    Chicago, IL
The Blue Cross and Blue Shield Association is a membership organization of independently owned insurance companies and is the strategic leader behind the Blue Cross Blue Shield brand, one of the most recognized brands in America and the choice of nearly 100 million Americans for their health care coverage. We now have two outstanding positions available for RNs in our downtown Chicago headquarters.
 
The Project Manager, Blue Distinction Clinical (site visit and quality) position will focus on three areas requiring clinical background: site visits, network quality, and facility data evaluation.. Responsible for leading multiple projects, services and associated deliverables primarily related to the Blue Distinction (BD) program. Functions as an information resource on BD administrative and clinical procedures contributing to the assimilation of data and the development of value added resources for Plans. Participates on smaller focused project teams as a technical/analytical resource.
 
The Project Manager, Blue Distinction, Research or Analytical position will focus on one of two areas, one research and the other data. Responsible for managing multiple complex projects, services and associated deliverables related to Blue Distinction (national specialty program development and management). Functions as an internal resource, assimilating trend and request information into sound strategic recommendations resulting in value added resources for all Plans. Participates and may lead larger more complex projects functioning as a technical and subject matter resource. Focuses on center credentialing, tracking/reporting, communication, customer service and efficiencies.
 
Required basic qualifications for both positions include current IL RN license or a Masters in Public Health, and a minimum of five years experience in a healthcare/hospital setting.
 
Preferred basic qualifications for both positions include knowledge of the managed care industry and excellent communication, project management skills, and transplant experience (site visit only).
 
For detailed job qualifications, please see our online posting when you apply.

We offer an exciting opportunity to bring your skills and talents to a dynamic organization committed to providing the most advanced technology and services. We offer great benefits package, work & family balance, a diverse workplace and much more! Please apply online by going to: https://bcbsa.igreentree.com/CSS_External/CSSPage_Welcome.asp and search for job number 07-158-. www.BCBS.com EOE.
 

  • Utilization Review Coordinator
Seeking a New Career Direction? Are you looking for a way to utilize your valuable clinical knowledge in a challenging business environment? Look no further!  We are recruiting for a self-starter who is collaborative, resourceful, motivated, energetic and loves a challenge. You will be working alongside a dynamic, knowledgeable team of RN’s with diverse clinical backgrounds.
 
HMA, conveniently located in Bellevue, has been a leader in the Third-Party Administrator (TPA) Industry for more than 20 years offering a variety of products and services for employers and the group health plans they sponsor.
 
The Utilization Review Coordinator (RN) is responsible for all aspects of Utilization Management activities including preauthorization, concurrent review and retrospective review, in accordance with written clinical review criteria and the health plan contracts. Significant attention to detail and accuracy are essential. This role is in a unique position to positively impact our clients’ and their members’ health care experience as well as optimize our clients’ health plan’s performance and design.
 
Requirements
  • Current WA State RN License
  • 1 year utilization review exp (preferred)
  • 5 years clinical nursing exp
  • Extensive med procedure and UR process knowledge
  • Experience with MS Word & Excel
Healthcare Management Administrators (HMA) believes in delivering superior value to our many self-funded Northwest clients by combining competitive rates with superior service. If you like our philosophy and would like to learn more about our organization, please E-mail your resume, cover letter and salary history to: recruiter@hma.regence.com. Faxed resumes are welcome at 305/574-0443. Be sure to visit our website at www.accesshma.com.
 

  • Director, Performance Improvement
    Metairie, LA
Description
 
Duties
Responsible for strategic and operational collaboration with department managers to identify, analyze, and trend clinical quality issues and collaborate to identify and implement successful solutions at the medical center. Manages, in partnership with medical staff and administrative leadership, the development of best practice order sets, and operations standards. Also, guides continuous accreditation compliance and guides the education and training associated with this and other programs. Directs the timely submission of abstracted clinical data to external agencies, and internal leadership. Independently makes decisions that could affect the overall division and/or medical center’s financial objectives, clinical performance targets and strategic results. Develops and is accountable for budget for department or multiple functional areas.
 
Required Qualifications
Masters degree in business administration, health administration or similar degree programs desired. Prior experience in
operations improvement and integration of strategy, finance and operational management recommended.
 
Please direct all inquires to Dave Mara at 804.527.1905 or email him at dmara@namcp.org.
 

United Health Group Companies are looking for nurse executives in New York City and Philadelphia for public sector business.  For details contact Jenni at jfriedman@uhc.com or call 952-936-3869.

 

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