Director, Care & Utilization Management

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POST DATE 9/13/2016
END DATE 10/29/2016

Visiting Nurse Service Of New York Brooklyn, NY

Company
Visiting Nurse Service Of New York
Job Classification
Full Time
Company Ref #
2320052
AJE Ref #
576159443
Location
Brooklyn, NY
Experience
Mid-Career (2 - 15 years)
Job Type
Regular
Education
Bachelors Degree

JOB DESCRIPTION

APPLY
RESPONSIBILITIES AND QUALIFICATIONS:

PURPOSE OF POSITION

Oversees VNSNY CHOICE Health Plan s care management operations for Medicare and FIDA. Collaborates with product line senior leadership in the development of the departmental strategic goals and objectives consistent with the overall VNSNY CHOICE strategic goals and financial targets. Ensures implementation of Quality Improvement (QI) programs and initiatives related to care management and service operations to ensure services provided meet the needs of the member. Works strategically to advance VNSNY CHOICE status as a World Class health plan to the community and regulatory agencies. Ensures compliance with all Federal & State Regulations and Requirements and Corporate Policies.

RESPONSIBILITIES

Partners with CHOICE leadership in the development and implementation of care mnagement strategic plans, goals and objectives that are aligned with the Health Plan and VNSNY s overall strategic goals. Serves as the DOH mandated Director of LTSS services per the FIDA program. Ensures that strategic plans, goals and financial targets are implemented within the business units to support the growth and profitability of the plan.

Functions as the thought leader for the team. Directs the development, revision, and implementation of Medicare and FIDA/ LTSS (CM/FIDA/LTSS) care management policies and procedures, to ensure alignment between processes and Federal and NYS health plan regulations.

Collaborates with Utilization Management counterpart to develop programs that support care coordination such as inpatient discharge planning or transitions of care,

Collaborates with quality department to set quality goals and establish methods and tools for staff audits, evaluation, and assessments. Monitors overall results, identifies trends, reports on findings, and makes recommendations for improvements.

Identifies, monitors, and evaluates key performance indicators, trends and needs of members and member services; develops strategies to address areas of opportunity to improve.

Evaluates effectiveness of Medicare, FIDA and LTSS Care Management using benchmark and objective data, including but not limited to, member health outcomes, satisfaction survey results (CAHPS), utilization metrics, and HEDIS star ratings. Ensures processes result in cost effective utilization of services and continued access to quality care as appropriate to assigned product line.

Ensures that all Medicare, FIDA Care Management and LTSS activities and operations are in compliance with federal, state and local health care regulations and standards of accrediting organizations; oversees periodic review and audit to ensure compliance with program policies, state and federal regulations.

Collaborates with Education Department in identifying/updating orientation and ongoing training needs for staff. Assists in delivering orientation and training. Assesses orientation and training programs to ensure effectiveness.

Ensures infrastructure efficiencies that enable the delivery of operationally excellent, high quality services.

Collaborates with health plan leadership and marketing department to support the development of marketing plans. Participates in outreach activities to promote plan growth. Increases public awareness of the program through education, presentations, publications, and marketing activities.

Oversees multi system integrity, upgrades, customization and reporting to ensure departmental efficiencies and regulatory compliance.

Provides oversight of Medicare and FIDA Care Management and LTSS services delegated to vendors which includes, but is not limited to, review of entities policies and procedures, utilization data and member health outcomes. Identifies areas of concern and assists in development of corrective action plans, as appropriate.

Serves as the DOH mandated Director of LTSS services per the FIDA program..

Develops and supports relationships with providers that result in continued improvement in quality healthcare outcomes. Drives efforts to engage providers in collaborative efforts during care transitions.

Collaborates with VNSNY CHOICE leadership to ensure budgetary compliance. Ensures Medicare and FIDA Care Management and LTSS are consistent with the plans budget.

Interprets and enforces Health Plan policiesas applicable.

Performs all duties inherent in a senior managerial role. Ensures effective staff training/cross training, evaluates staff performance, conducts regularly scheduled monitoring and oversight; development and implementation of corrective action plans when appropriate and approves hiring, promotions, salary actions and terminations.

Participates in special projects and performs other job duties as required.

Partners with CHOICE leadership in the development and implementation of care and utilization management strategic plans, goals and objectives that are aligned with the Health Plan and VNSNY s overall strategic goals. Ensures that strategic plans, goals and financial targets are implemented within the business units to support the growth and profitability of the plan.

Directs the development, revision, and implementation of Care and Utilization Management (CM/UM) policies and procedures, to ensure alignment between processes and Federal and NYS health plan regulations.

Collaborates with quality department to set quality goals and establish methods and tools for staff audits, evaluation, and assessments. Monitors overall results, identifies trends, reports on findings, and makes recommendations for improvements.

Identifies, monitors, and evaluates key performance indicators, trends and needs of members and member services; develops strategies to address areas of opportunity to improve.

Evaluates effectiveness of CM/UM operations using benchmark and objective data, including but not limited to, member health outcomes, satisfaction survey results (CAHPS), utilization metrics, and HEDIS star ratings. Ensures processes result in cost effective utilization of services and continued access to quality care as appropriate to assigned product line.

Ensures clinical criteria and guidelines are implemented consistent with evidenced based protocols.

Ensures that all CM/UM activities and operations are in compliance with federal, state and local health care regulations and standards of accrediting organizations; oversees the periodic review and audit to ensure compliance with program policies, state and federal regulations.

Collaborates with Education Department in identifying/updating orientation and ongoing training needs for staff. Assists in delivering orientation and training. Assesses orientation and training programs to ensure effectiveness.

Ensures infrastructure efficiencies that enable the delivery of operationally excellent, high quality services.

Collaborates with health plan leadership and marketing department to support the development of marketing plans. Participates in outreach activities to promote plan growth. Increases public awareness of the program through education, presentations, publications, and marketing activities.

Oversees multi system integrity, upgrades, customization and reporting to ensure departmental efficiencies and regulatory compliance.

Provides oversight of CM/UM functions delegated to vendors which includes, but is not limited to, review of entities policies and procedures, utilization data and member health outcomes. Identifies areas of concern and assists in development of corrective action plans, as appropriate.

VNSNY is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to race, color, religion, sex, national origin, disability or protected veteran status. If you would like more information about your EEO rights, then please visit:

http://www.vnsny.org/system/assets/0000/3510/eeopost.original.pdf?1394816984
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