AVP Care Coordination
Description
Summary: The System Care Coordination Leader will serve as a pivotal force in optimizing patient care and resource utilization across Nuvance Health. This leader is responsible for providing strategic leadership and operational oversight for a team of utilization review staff, denials and appeals specialists, non-clinical support staff while partnering with local case management leadership. This individual will support the pursuit of excellence in care coordination, discharge planning, resource stewardship, and regulatory compliance, ultimately contributing to improved patient outcomes, reduced lengths of stay, enhanced organizational efficiency, and maximized reimbursement through denial reduction and successful appeals.
The System Care Coordination Leader will be responsible for leading a team encompassing utilization review and denials/appeals specialists and will need to foster a culture of collaboration, patient-centered care, and revenue optimization. This leader empowers denials/appeals specialists to meticulously investigate denied claims, prepare comprehensive appeals, and collaborate with clinical staff to ensure successful outcomes. Simultaneously, they drive the development and implementation of evidence-based care pathways, enhancing care transitions and optimizing resource utilization across the entire care continuum.
Essential Responsibilities
- Strategic Leadership & Vision:
- Strategic Planning: Develop and implement a comprehensive, patient-centric vision and strategy for system-wide care coordination, encompassing utilization review (UR), denials management, discharge planning, social work, and non-clinical support staff. Align this strategy with organizational goals, quality metrics, and financial sustainability.
- Performance Excellence: Establish clear departmental goals, key performance indicators (KPIs), and robust data-driven metrics to track success across all care coordination functions. Regularly report progress to executive leadership.
- Culture of Collaboration: Foster a positive, high-performing team culture that values collaboration, innovation, continuous improvement, and patient-centered care. Mentor and empower staff to achieve their full potential.
- Organizational Advocacy: Champion the critical role of care coordination in optimizing patient outcomes, resource utilization, and financial performance. Actively participate in organizational leadership discussions to advocate for resources and support.
- Utilization Review Committee: Establish committee to ensure CMS and regulatory compliance. Develop and maintain a UM plan to guide the team with detailed processes and procedures. Attend and contribute to the UR committee meetings.
- Utilization Review (UR):
- Proactive UR: Lead a team of UR nurses to conduct timely and thorough pre-authorization reviews, ensuring medical necessity and appropriate level of care. Develop clinical criteria and guidelines for efficient UR processes.
- Concurrent Review: Oversee the concurrent review process, monitoring patient progress, verifying continued need for services, and facilitating timely discharge planning.
- Post-Acute Care Coordination: Collaborate with post-acute care providers to ensure smooth transitions of care, prevent readmissions, and optimize patient outcomes.
- Denials Management & Appeals:
- Root Cause Analysis: Lead a specialized team to thoroughly investigate claims denied for medical necessity on bedded patients, identify root causes (clinical documentation, coding, etc.), and develop corrective action plans to prevent future denials.
- Appeals Expertise: Oversee the preparation and submission of comprehensive appeals, ensuring accuracy, clinical validity, and adherence to payer requirements. Monitor appeal outcomes and adjust strategies as needed.
- Data-Driven Improvement: Utilize denials data to identify trends, prioritize improvement efforts, and negotiate with payers for fair reimbursement.
- Physician Advisor Collaboration: Collaborate with the physician advisor (PA) group and leader to ensure processes and goals are aligned; including peer-to-peer results, observation rates, observation conversion rates, medical necessity outreach, and feedback to the utilization review team on denial outcomes.
- Discharge Planning & Social Work:
- Patient-Centered Planning: Partner with and provide support to entity specific social workers and discharge planners to develop individualized discharge plans that address medical, social, and emotional needs. Ensure patient/family education and engagement.
- Resource Navigation: Provide assistance, as needed, to connect patients with appropriate community resources, support services, and post-acute care options. Address barriers to care and advocate for patient needs.
- Readmission Prevention: Collaborate effectively to implement strategies to reduce readmissions through proactive discharge planning, follow-up care coordination, and community partnerships.
- Non-Clinical Support Staff:
- Optimization: Supervise and empower non-clinical staff (e.g., administrative assistants, data analysts) to support care coordination processes through data management, scheduling, communication, and resource tracking.
- Efficiency: Continuously evaluate and refine workflows to maximize efficiency, reduce administrative burden, and free up clinical staff to focus on patient care.
- Financial Stewardship & Compliance:
- Budget Management: Develop and manage departmental budgets, ensuring cost-effective operations and optimal resource allocation. Track and report on financial performance.
- Revenue Cycle Optimization: Collaborate with revenue cycle teams to maximize reimbursement, reduce denials, and capture appropriate revenue for care coordination services.
- Regulatory Compliance: Ensure adherence to all relevant federal, state, and local regulations, accreditation standards, and payer requirements. Maintain up-to-date knowledge of changing healthcare policies.
- Maintain and Model Nuvance Health Values.
- Demonstrates regular, reliable and predictable attendance.
- Performs other duties as required.
Education and Experience Requirements:
- Bachelor's degree in nursing (BSN)
- Master's degree in nursing, health administration, or a related field preferred
- Current licensure as a registered nurse (RN)
- Minimum of 5 years of clinical experience in an acute care setting
- Minimum of 5 years of progressive leadership experience in case management or utilization review
- Proven leadership experience with a track record of success in managing and motivating teams
- Strong knowledge of healthcare regulations, accreditation standards, and payer requirements
- Excellent analytical, communication, interpersonal, problem-solving, and decision-making skills
- Experience with data analysis and performance improvement methodologies
- Commitment to patient-centered care and interdisciplinary collaboration
- Effective communication and interpersonal skills, with the ability to build relationships with diverse stakeholders
Minimum Knowledge, Skills and Abilities Requirements:
- Familiarity and competence with Windows applications
- Excellent verbal and written communication skills
- Self-motivation, initiative, and decision making skills
- Effective interpersonal skills which foster a team approach to problem solving and ensure high degree of customer satisfaction
- Ability to act professionally, independently and efficiently
- Demonstration of service excellence and the ability to incorporate the mission and core values into daily activities
- High energy, flexible, optimistic, attitude with ability to handle multiple demands
- Knowledge of third-party payer reimbursement and denial management
- Experience in applying and utilizing InterQual and/or Milliman Care Guideline criteria for patient status determination
- Experience with a healthcare software system including EMR (clinical and financial) is highly desired
License, Registration, or Certification Requirements:
- CT or NYS RN License
Working Conditions:
Manual: significant manual skills/motor coord & finger dexterity
Occupational: Little or no potential for occupational risk
Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force
Physical Environment: Generally pleasant working conditions
Credentials: RN
Company: Nuvance Health
Org Unit: 1822
Department: Rev Cycle Admin
Exempt: Yes
Salary Range: $78.97 - $146.65 Hourly