Manager, Medical Management Outcomes

Rego Park, NY

Posted: 03/04/2019 Job Number: 25601
Position Purpose:
  • 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. 

Qualifications:
  • 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.
For more information on this position, please contact our office at 877-782-3334.
 

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