Senior Director, Medical Management Operations

Atlanta, GA 30301

Post Date: 01/29/2018 Job ID: 25758 Category: Professional

Job Description:
  • Drive execution of Corporate Medical Management projects and initiatives to bring greater effectiveness, efficiency and consistency across Health Plans.
  • Develop effective and innovative medical management programs, processes, and models keeping abreast of medical trends, industry changes and state requirements.
  • Evaluate existing medical management practices across Health Plans.
  • Facilitate cross-functional/cross-Health Plan work teams to identify best practices and improvement opportunities.
  • Develop work plans and drive execution.
  • Utilize continuous process improvement techniques to explore approaches to work processes to eliminate waste and ensure resources are allocated to high value activity.
  • Develop and drive implementations of new medical management processes/programs.
  • Establish standardized "play books" to ensure effectiveness and efficiency.
  • Collaborate with Health Plans and Corporate Medical Affairs to ensure accreditation standards are achieved in Utilization Management and Case Management.
  • Partner with Specialty Companies and Health Plans to implement programs and processes to efficiently improve member outcomes.
  • Maintain corporate level policies and procedures.
  • Collaborate with Health Plans to adopt and modify Health Plan specific requirements to ensure compliance with state contractual requirements.
  • Provide overall direction to Corporate Medical Management Training team.
  • Collaborate with Medical Management Systems to ensure appropriate infrastructure is in place to execute new programs and processes.
  • Develop consistent key performance metrics to monitor Medical Management processes.
  • Analyze data to evaluate effectiveness of existing and new medical management programs, and modify programs based on findings.

  • Bachelor's degree in Nursing or related field.
  • 7+ years of related Medical Management experience in a managed care environment.
  • Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
  • RN license preferred.
  • Quality, reporting and analytics experience is highly desired.
  • Strong training experience is a preferred.
  • Familiar with NCQA and CMS standards is desired.
  • Six Sigma Certification is a plus.

For more information, please contact our office at 877-782-3334.



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