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RN Manager, A&G Clinical Review
2 months ago
The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.
Directly responsible for management and end to end processing of clinical appeals, grievances and quality of care concerns that conforms with and /or exceeds regulatory requirements for DOH and CMS, health plan guidelines and operational policy and procedure. Collaborate with other A&G Management staff as needed to ensure all tasks are handled. Accurately collects and reports on key performance indicators for all clinical review processes and performance indicators. Accurately capture reporting elements for analysis and offer recommendations where opportunities for improvement are identified. Assist with leading ongoing quality improvement efforts. Monitors outcomes of Quality of Care concerns as identified through appeal and grievance processing, internal or external referral. Work closely with the Director of A&G, Delegated Vendor Unit (NPO), Service Operations and other Departments for continuous improvement in the identification and triage of any potential A&G issues. Provides feedback as needed. Functions as the A&G Clinical review lead for all regulatory audit functions. Assists in preparation and verification for accurate generation of audit universes and sample files. Lead clinical participant for all aspects of audit process. Prepares clinical corrective action plans as necessary. The audits include those by CMS, DOH, and other regulatory bodies or Plan initiated reviews. Upon receipt, reviews appeal outcomes from IRE or ALJ. Uses the information provided as source of opportunity for continuing education and quality enhancement for the A&G clinical team. If trends are identified, shares outcome information with Utilization and Care Management Departments to assist in the review process for initial organizational determinations. Liaison with Health Plan Medical Director on complex clinical reviews. Maintains the coverage schedule if other physician reviewers are necessary. Ensure that ample Clinical Review A&G staff coverage is provided, and cases responded to in accordance with all regulatory timeframes. Manages performance of direct reports. Provides orientation, coaching, training and development. Takes corrective action when necessary. Utilizes corporate services resources such as Human Resources, Compliance, Legal, Finance, Information Services, Marketing, etc., as appropriate. Interviews and participates in the selection process for qualified staff in collaboration with Human Resources and department management.
- Bachelor’s Degree required. Master’s preferred
- 5 plus years’ experience in managed care including appeals and grievance and/or compliance
- 2 years’ prior supervisory or management experience preferred
- Strong knowledge of federal, state and managed healthcare regulations and requirements
- NYS RN License Degree. Strong leadership skills
- Detail oriented. Excellent computer software skills including Microsoft Office, Access, PowerPoint, MS Project
