Senior Director of Managed Care/ Denials

Overview

John's Riverside Hospital is a leader in providing the highest quality, compassionate health care utilizing the latest, state-of-the-art medical technology. Serving the Westchester community from Yonkers to the river town communities of Hastings-on-Hudson, Ardsley, Dobbs Ferry and Irvington, St. John's Riverside has been and continues to be a unique and comprehensive network of medical professionals dedicated to a tradition of service that spans generations.

St. John’s has been an integral part of the community since the 1890's and its’ commitment to provide the community with the most advanced medical services available continues to be the hospitals’ vision, mission and value. St. John's Riverside Hospital built itself around an early foundation of nursing and community service. In 1894, the Cochran School of Nursing, the oldest hospital-based school of nursing in the metropolitan area, was founded, thus making the St. John's Nursing Staff more than just the backbone of the hospital, but the heart and soul. St. John’s dedicated nurses give superior attention to those who need it most with a strong emphasis on patient and family-focused nursing care.   

St. John’s Riverside Hospital staff is committed to making life better for all patients. The hospital continues to elevate the services provided with the goal of increasing the quality of  life for all who entrust St. John's Riverside Hospital to their care.

St. John’s Riverside Hospital is an equal opportunity employer. We maintain a policy of non-discrimination in providing equal employment to all qualified employees and candidates regardless of race, creed, color, national origin, sex, age, disability, marital status, or other legally protected classification in accordance with applicable federal, state, and local law.

Personalized care together with advanced technology is what it means to be Community Strong

Responsibilities

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.

Qualifications

• Required RN license in NY, BSN
• Preferred Master of Science in Nursing (MSN), Master of Healthcare Administration (MHA), or Master of Business Administration (MBA) with a focus of healthcare.
• Preferred certification in Case Management (CCM), Nurse Executive (NE-BC), or Director of Nursing Services (DNS-CT).
• Minimum 3 – 5 years of acute care leadership experience, with at least 2 years as a Director of Case Management.
• Minimum of 2 years current Behavioral Health Experience and a minimum of 5 years of progressive leadership experience in case management and utilization review.
• Regulatory expertise: In-depth knowledge of federal, state, and industry regulations governing managed care and reimbursement and OASAS regulations.