Associate Director Managed Care Clinical Operations
Visiting Nurse Service of New York - Manhattan, NY

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Managed Care Operations is a department comprised of clinical and business staff who are responsible for the verification of patients’ managed care fiscal and benefit package. MCS Operations also obtains authorization approval from managed care payors for initial and ongoing requests for home care services. Obtaining approval is a process that involves knowledge of managed care organizations and the regulations that govern them, experience with health care operations, clinical expertise and business acumen to advocate for VNSNY’s patients. Responsible for implementing, organizing and directing staff and functions that provide clinical support to the agencys managed care department.

Manages clinical case reviews; implements and manages the use of InterQual criteria for reviews; conducts utilization review studies, Inter-Rater Reliability studies and provides reports for payers on rates of utilization for their enrollees; oversees the denials/appeals management process through coordination with Patient Accounts and the conduct of clinical reviews and regulatory interpretation; oversees clinical and non-clinical education for the Managed Care Services (MCS) unit; oversees quality assurance and audit for the MCS unit; and liaises with various departments (e.g. Business Development, Acute Care, Rehab) to improve performance of the managed care function and foster collegial relationships with the department. Ensures service quality, and adherence to NY State and Federal regulations governing health/homecare/managed care operations. Acts as liaison to payers, managed care organizations and appropriate VNS departments/regions.

Serves as a clinical expert resource on regulations and laws pertaining to authorizations and denials. Monitors payer/managed care trends. Works under general direction. License: License and current registration to practice as a Registered Professional Nurse in NY State required.Education: Associates degree in Nursing required, Bachelors Degree in Nursing preferred.

Experience: Minimum of five years professional nursing in a leadership role within a managed care organization required. Strong knowledge of operations of manual and automated office systems and procedures required. Knowledge of Medicare/Medicaid and Managed Care Regulations required. Experience with managed care appeals and denials management required.

Knowledge of NY State and Federal regulations governing homecare operations preferred. Proficient PC skills, including MS Word and Excel preferred.

Visiting Nurse Service of New York - 16 months ago - save job - block
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When you're laid up in bed, Visiting Nurse Service of New York (VNSNY) can give you something besides your afternoon soap operas to...