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.

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.

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.

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.

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.

Budget Management : Develop and manage departmental budgets, ensuring cost-effective operations and optimal resource allocation. Track and report on financial performance.

Education and Experience Requirements :

Minimum Knowledge, Skills and Abilities Requirements :

License, Registration, or Certification Requirements :

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