NYC Health Hospitals
Associate Director of Nursing (Associate Director of Managed Care Contract)
NYC Health Hospitals, New York, New York, us, 10261
NYC Health + Hospitals/Coler is an 815-bed nursing facility with a 5-Star CMS Quality Rating located on Roosevelt Island, nestled between Manhattan and Queens. Coler offers long term and subacute care, rehabilitation, and a dedicated memory care unit, comprised of 150 beds featuring an acclaimed music and memory program. The facility features a robust rehabilitation therapy program with expansive gym space for residents. Coler also offers full time physician staff, psychiatry, dental services, an onsite 8-chair dialysis den for hemodialysis, and on-site medical clinics to meet the clinical needs of its residents.
From more than 600 Nursing Homes, Coler ranks #5 in Newsweek's Best Nursing Homes in New York 2024; and also received a 2024 Silver Beacon Award for Memory Care.
At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.
Job Description
Position 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 Qualifications
Minimum Qualifications:1. MINIMUM QUALIFICATIONS: Licensed and currently registered to practice as a professional nurse in New York State, plus (2) or (3) below:2. Master's Degree in nursing administration, education or an equivalent field and a minimum of six years of satisfactory nursing experience; four of which shall have been in supervisory, teaching or administrative capacity; or3. A baccalaureate degree in nursing and seven years of satisfactory nursing experience, five of which shall have been in a supervisory or teaching capacity; or4. A satisfactory equivalent combination of education and experience.
Departmental 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
If you wish to apply for this position, please apply online by clicking the "Apply Now" button
NYC Health and Hospitals offers a competitive benefits package that includes:
Comprehensive Health Benefits for employees hired to work 20+ hrs. per weekRetirement Savings and Pension PlansLoan Forgiveness Programs for eligible employeesPaid Holidays and Vacation in accordance with employees' Collectively bargained contractsCollege tuition discounts and professional development opportunitiesMultiple employee discounts programs
From more than 600 Nursing Homes, Coler ranks #5 in Newsweek's Best Nursing Homes in New York 2024; and also received a 2024 Silver Beacon Award for Memory Care.
At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.
Job Description
Position 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 Qualifications
Minimum Qualifications:1. MINIMUM QUALIFICATIONS: Licensed and currently registered to practice as a professional nurse in New York State, plus (2) or (3) below:2. Master's Degree in nursing administration, education or an equivalent field and a minimum of six years of satisfactory nursing experience; four of which shall have been in supervisory, teaching or administrative capacity; or3. A baccalaureate degree in nursing and seven years of satisfactory nursing experience, five of which shall have been in a supervisory or teaching capacity; or4. A satisfactory equivalent combination of education and experience.
Departmental 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
If you wish to apply for this position, please apply online by clicking the "Apply Now" button
NYC Health and Hospitals offers a competitive benefits package that includes:
Comprehensive Health Benefits for employees hired to work 20+ hrs. per weekRetirement Savings and Pension PlansLoan Forgiveness Programs for eligible employeesPaid Holidays and Vacation in accordance with employees' Collectively bargained contractsCollege tuition discounts and professional development opportunitiesMultiple employee discounts programs