Responsible for directing the case management, medical review, utilization review, quality management, audit, and /or health education programs. Provides strategic planning, project management, budget planning, decision making, and direction of a quality, cost effective delivery system providing health services to members.

Responsible for the development, implementation and management of the Health Services functions. May manage inpatient and outpatient medical costs at levels consistent with the plan’s objectives. May assist in the coordination of network management activities and/or the development of provider reimbursement methodologies. May administer grievance, appeal, provider dispute, heath risk assessment, diseases management, or life enhancement functions. Responsible for compliance with company, state, and federal policies, procedures, and regulations. May implement quality management process policies and procedures, provide training to staff, manage individual case review and investigation, and oversee NCQA process and HEDIS reporting.

Required Experience

Minimum Requirements

Bachelor’s degree or equivalent work experience. Seven or more years experience in utilization/quality management. Five or more years’ management experience. Broad knowledge of managed care concepts. Preferred Requirements: Master’s Degree. Active Registered Nurse (RN) license, Licensed Physical Therapist (LPT), Licensed Respiratory Therapist (LRT), Licensed Social Worker (LSW), Registered Dietitian (RD), or Psychologist.