AVP Care Coordination

Description

• 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.

• 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

• Familiarity and competence with Windowsapplications
• Excellentverbalandwrittencommunicationskills
• Self-motivation,initiative,anddecision makingskills
• Effective interpersonal skills which foster a team approach to problemsolvingandensurehighdegreeofcustomersatisfaction
• Abilitytoactprofessionally,independentlyandefficiently
• Demonstrationofserviceexcellenceandtheabilitytoincorporate the mission and core values into daily activities
• Highenergy,flexible,optimistic,attitudewithabilitytohandle multiple demands
• Knowledgeofthird-partypayerreimbursementanddenial management
• ExperienceinapplyingandutilizingInterQual and/or Milliman Care Guideline criteriafor patient status determination
• ExperiencewithahealthcaresoftwaresystemincludingEMR (clinical and financial) is highly desired 

• 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