Manager, Medical Management Outcomes
Rego Park, NY
- Evaluate, design, develop and implement medical management initiatives to support the business needs through various clinical analysis.
- Develop and analyze various clinical data and reports on medical management programs, including authorization, utilization and case/disease management.
- Develop databases, set benchmarks, identify root cause and recommend improvements.
- Develop, create and implement database or automation to support and eliminate manual updates to programs within medical management.
- Research, identify and monitor provider utilization trends and monitor providers for adherence to contract provisions.
- Report trends and refer cases for further investigation.
- Conduct audits and ensuring consistency with all contractual requirements.
- Respond to all inquiries related to provider assignments.
- Establish criteria and strategy for pilot programs and advise on guidelines and system modifications that affect claims processing and payment decisions.
- Education/Experience: Bachelor’ s degree in Healthcare, Business, Quantitative science or related field. 4+ years business or clinical data analysis.
- Experience with medical coding practices, groupers and reimbursement practices.
- Comprehensive knowledge of current medical practices covering a broad range of medical specialties especially neonates and newborns.
- Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
- Provider and claim systems (CCMS and Amisys) experience preferred.
- Knowledge of ICD-9, DRG’ s and CPT codes preferred.
- Database management, SQL, Crystal Reports and/or COGNOS experience preferred.