Work Shifts9:00 A.M - 5:00 P.MDuties & ResponsibilitiesPosition Overview: The Associate Director of Managed Care Contract Manager with a clinical background, will use their clinical expertise and managed care experience to oversee and manage all aspects of managed care contracts. This includes ensuring smooth operations, effective care coordination, and optimal financial performance. The role involves close collaboration with the Central Office's Managed Care Team and Managed Care Organizations (MCOs) to drive contract performance and continuous improvement.
Essential Functions:Coordination of Care:
- Support escalations to Central Corporate Managed Care regarding issues with MCOs to ensure smooth operations and prompt resolution of problems.
- Facilitate seamless care coordination between facilities, MCOs, and other healthcare providers to ensure optimal resident outcomes.
Contract Management - Negotiation:
- Prepare for contract negotiations with MCOs in collaboration with the Central Office Managed Care Team to establish favorable contract terms and reimbursement rates.
- Review and assess performance metrics to inform negotiation strategies.
Contract Performance:
- Monitor and evaluate facility performance against contractual obligations.
- Assess MCO performance to ensure adherence to contractual terms and prompt resolution of any discrepancies.
Utilization Review Reporting:
- Conducted and summarized concurrent and retrospective reviews of resident/patient care authorizations in alignment with agreed contract terms by the MCOs.
- Ensure timely and accurate reporting of utilization review outcomes to relevant stakeholders.
Denial Management:
- Analyze and report on denial trends, identifying key issues and the effectiveness of the appeals process.
- Collaborate with Managed Care Organizations (MCOs) to ensure compliance with the revised final rule for the Medicare Advantage Program issued by the Centers for Medicare & Medicaid Services (CMS).
Continuous Improvement:
- Implement quality improvement initiatives based on performance data, feedback from MCOs, and industry best practices.
- Drive improvements in contract management processes to enhance overall efficiency and outcomes.
Financial Reporting and Analysis:
- Prepare comprehensive analyses of MCO payments, identifying trends and areas for improvement.
- Collaborate with the finance department to ensure accurate reconciliation of authorizations and payments.
- Collaboration with the finance department to reconcile authorization for level or PDPM for claims paid by MCO
- Monitor contract performance, including payment accuracy, timeliness, and compliance with contract terms.
Performance Metrics and Benchmarking:
- Monitor and report on key performance indicators (KPIs) related to clinical and financial outcomes.
- Use KPIs to evaluate performance, guide improvement efforts, and compare results against industry benchmarks.
Regulatory Compliance:
- Ensure all managed care contracts comply with state and federal regulations, including CMS guidelines.
- Stay updated on changes in healthcare laws, regulations, and industry trends that may impact managed care contracts.
Cross-Departmental Collaboration:
- Work closely with Central Case Management during MCOs contract negotiations and management.
- Partner with clinical departments to support documentation and care coordination for ongoing authorizations.
- Coordinate with the admissions department to ensure proper pre-certification of initial authorizations
- Collaboration with the finance department to reconcile authorization for level or PDPM for claims paid by MCO
Performs related duties, as required.
Minimum Qualifications1. Valid New York State license and current registration to practice as a Registered Professional Nurse in New York State; and
2. Master's Degree from an accredited college or university in Nursing Administration or a related nursing discipline; and three (3) years of satisfactory nursing experience, two (2) years of which must have been in a responsible administrative or supervisory capacity, which may include managing a specific department or nursing unit within a hospital, overseeing patient care, staff management and the day-to-day operations of the department, as well as relevant clinical nursing experience in the area of nursing practice assigned; or
3. Bachelor's Degree from an accredited college or university in Nursing; and four (4) years of satisfactory nursing experience, three (3) years of which must have been in a responsible administrative or supervisory capacity described in 2 above.
4. May require Basic Life Support (BLS) through the American Heart Association (AHA) depending on assignment/health care setting. If required, BLS must be obtained within sixty (60) calendar days of appointment to the title and maintained for the duration of the assignment.
Department Preferences- Proven experience in managed care contract management, with strong negotiation skills.
- In-depth understanding of healthcare reimbursement models and performance metrics.
- Strong clinical background with extensive knowledge of clinical terminology and the ability to interpret clinical documentation for contract and utilization review purposes
- Excellent analytical, communication, and collaboration skills
- Ability to drive continuous improvement initiatives based on clinical data and performance metrics.
- Proficient in the utilization of EMR systems and Microsoft Office Suite
BenefitsNYC Health and Hospitals offers a competitive benefits package that includes:
- Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
- Retirement Savings and Pension Plans
- Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
- Loan Forgiveness Programs for eligible employees
- College tuition discounts and professional development opportunities
- College Savings Program
- Union Benefits for eligible titles
- Multiple employee discounts programs
- Commuter Benefits Programs
If you wish to apply for this position, please apply online by clicking the "Apply for Job" button.
