Senior Director of Managed Care/ Denials

St. John's Riverside Hospital • City of Yonkers, NY

121d

About The Position

The Senior Director of Managed Care and Denials is a senior leadership position responsible for directing and overseeing all aspects of managed care. The director will enhance the throughput of patients, reimbursement received through appropriate status utilization, coordination of care, length of stay management and discharge disposition management. Familiar with OASAS and TJC guidelines. Oversees discharge planning and utilization review of cases throughout the hospital system. BHS compliance with current OASAS and TJC standards. Directs development of specific short- and long-range programs and projects plans to achieve the facility’s goals and objectives. Establishes department policies and procedures. Establishes best practices for department and staff. Responsible for overseeing patient Length of Stay. Prepares monthly statistics and manages department database. Ensures staff is trained and using Milliman and LOCADTRs. Coordinates the Utilization Review process and participates in related interdisciplinary committees and working groups. Coordinates the review and response process for denials. Implements process to avoid hospital denials. Responsible for the planning and coordination of department activities, the operational efficiency and effectiveness of the department. Responsible for hiring, firing, discipline and performs performance appraisals for all Case Management. Responsible for ensuring the department meets and adheres to all applicable federal, state, JCAHO, OASAS, and local regulatory agency requirements. Participates on various committees and other task forces as may be established by management to plan, organize and drive the facility. Prepares the performance improvement reports quarterly for presentation at Performance Improvement committee meeting. Confers with other department directors when necessary to resolve procedural difficulties, clarifying department responsibilities, objectives and resolving identified problems. Makes recommendations on insurance company contract initiation, renewals, and termination. Weekly communication with Associate VP of Nursing pertaining to implementation strategies for the achievement of strategic vision and annual goals. Responsible for preparation and overall management of the annual budget for the departments.

Requirements

• Required RN license in NY.
• BSN.
• Minimum 3 – 5 years of acute care leadership experience.
• At least 2 years as a Director of Case Management.
• Minimum of 2 years current Behavioral Health Experience.
• Minimum of 5 years of progressive leadership experience in case management and utilization review.
• In-depth knowledge of federal, state, and industry regulations governing managed care and reimbursement.

Nice To Haves

• Master of Science in Nursing (MSN).
• Master of Healthcare Administration (MHA).
• Master of Business Administration (MBA) with a focus on healthcare.
• Certification in Case Management (CCM).
• Nurse Executive (NE-BC) certification.
• Director of Nursing Services (DNS-CT) certification.

Responsibilities

• Direct and oversee all aspects of managed care.
• Enhance patient throughput and reimbursement through appropriate status utilization.
• Manage coordination of care, length of stay, and discharge disposition.
• Oversee discharge planning and utilization review of cases.
• Ensure compliance with OASAS and TJC standards.
• Develop short- and long-range programs and project plans.
• Establish department policies and procedures.
• Implement best practices for department and staff.
• Oversee patient Length of Stay and manage department database.
• Ensure staff training on Milliman and LOCADTRs.
• Coordinate the Utilization Review process.
• Participate in interdisciplinary committees and working groups.
• Coordinate the review and response process for denials.
• Implement processes to avoid hospital denials.
• Plan and coordinate department activities for operational efficiency.
• Manage hiring, firing, discipline, and performance appraisals for Case Management.
• Ensure adherence to federal, state, JCAHO, OASAS, and local regulatory requirements.
• Participate in various committees and task forces.
• Prepare quarterly performance improvement reports.
• Resolve procedural difficulties with other department directors.
• Make recommendations on insurance company contracts.
• Communicate weekly with Associate VP of Nursing on strategic implementation.
• Prepare and manage the annual budget for the departments.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Bachelor's degree
• Number of Employees: 1,001-5,000 employees