Assist the Director in the coordination, implementation, monitoring and evaluation of quality and utilization activities related to outcomes management in accordance with CPHL, State and Federal mandates and regulations.
Develops and provides orientation to new nurse practitioners and routine training including operational policies and procedures, workflows, internet resources to new and existing nurse practitioner staff.
Manage and develop nurse practitioner staff by setting goals and providing daily feedback, redirection and coaching.
Serves as a resource to support high quality Model of Care, member advocacy, provider education, nursing home clinical staff in-service, benefit determinations and utilization analysis.
Conducts monthly team meetings with all NPs that includes agenda and minutes.
Develop and facilitate collaborative relationships with other members of the care team, operations staff and nursing home staff.
Ensures NP compliance with CPHL policies and procedures including authorization processes.
Conducts audits of NP activities to evaluate and improve performance.
Review cases with NPs to verify that care planning efforts are focused and prioritized.
Based on review of cases, prepares and distributes daily reports to Director and Medical Director about potential hospitalizations, actual hospitalizations, potential and actual transfers to and from hospitals.
Performs root cause analysis and identifies aberrant benefit or service deliver trends in conjunction with other members of site staff.
Participation on implementation team for new nursing homes.
Tracks, analyzes and reports information to identify barriers to effective care coordination including transfers to and from hospital.
Evaluates the consistency, thoroughness, quality and compliance of NPs documentation in the clinical medical record.
Identifies potential compliance issues that may affect the organization and develops action plans t address them.
Monitors NP on-call / call back activity.
Provides coverage for NPs.
Conducts performance reviews.
Participates in interview process and provides opinion.
Familiarity with data analysis & utilization trending.
Excellent interpersonal skills, negotiation skills, presentation skills.
Excellent verbal and written skills.
Excellent training and audit skills.
Minimum of three years supervisory experience with a managed care or insurance company.
This job operates in a professional environment. This role routinely uses standard equipment such as computers, phones, and photocopiers.
This is largely a sedentary role; however, some filing is required. This would require the ability to lift files, open filing cabinets and bend or stand as necessary.
Position Type and Expected Hours of Work
This is a full-time position. Half time at nursing facilities.
Required Education and Experience:
Masters Level Prepared, Nurse Practitioner, preferably Geriatric Nurse Practitioner.
Knowledge and working experience with Medicare, Medicaid and state/federal health care regulations.
NYS Nurse Practitioner license.
Certified of eligible to achieve Case Management Certification, a plus.