Manager of Claims Business Process Monitoring

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

Reporting to the Director of Business Process Monitoring, the Manager of Claims Business Process Monitoring is an essential part of the mandatory Compliance Program and is responsible for overseeing regularized auditing of claims processed by MetroPlusHealth. The Manager of Claims Business Process Monitoring will be tasked with ensuring that an effective system of routine auditing for identified compliance risks is maintained.

• Supports the Director of Business Process Monitoring in managing the day-to-day claims monitoring functions of the MetroPlusHealth Compliance Program.
• Identifies claims risks and contributes to the annual risk assessment and work plan.
• Develops and executes audits as issues are identified and in response to ad hoc requests.
• Manages a team of Compliance Claims Auditors. This includes development of training and tools, direct monitoring of audits, and investing in the team’s professional development.
• Oversees the daily functions of the Claims Business Process Monitoring team, which includes:
• Executing monitoring activities
• Identifying issues of non-compliance
• Communicating findings to appropriate business areas
• Assists in the development and monitors program dashboards and monitoring metrics to ensure the timely identification of and resolution of compliance issues.  
• Compiles and finalizes reports from the Claims Business Process Monitoring team for internal reporting purposes, including Vendor Delegation Oversight, Compliance Committee, and Audit and Compliance Committee.
  • Communicates audit progress and findings through various reporting mechanisms.
  • Track and trend emerging issues and how we may be able to respond on an organizational level.
• Upon identification of non-compliance, provides support to business areas in conducting a root cause analysis and corrective actions, including guidance on methodology, identification of relevant regulatory requirements and any regulatory compliance context, and Compliance review. 
• Plays a critical role in driving the progress for corrective actions throughout the organization.
• Collaborates with Claims, Operations, IT, Vendor Management, Vendor Compliance and the Vendor Delegation Oversight Sub-committee to ensure regulatory requirements are met by delegates and FDRs.
• Ensures proper investigation of all compliance related issues.
• Streamlines workflow by automating data collection processes, improving timeliness and accuracy of compilation processes.
• Keeps up to date on the latest developments, federal and state laws, and regulations.
• References, connects, and/or leverages data available from a variety of electronic sources. An aptitude for learning new systems and skills in analyzing data are a definite plus.
• Other activities as assigned by the Director of Business Process Monitoring.

• Bachelor’s degree from an accredited institution
• 5-7 years of experience in managed care organization compliance/auditing or healthcare compliance (experience with billing, claims process, Medicaid, Medicare, ACA, medical record review, investigation of problematic issues)
• Healthcare Compliance or Internal Audit Certification (preferred).

Professional Competencies

• Ability to function independently with limited direction.
• In depth knowledge of health care policy environments or policy related roles with demonstrated knowledge of leading and supporting cross-departmental employee stakeholders.
• Demonstrated knowledge of managing and building relationships with stakeholders, including senior management, with strong influencing and negotiation skills.
• Excellent written English, with proven ability to research and edit accessible, clear policy and procedure documents as well as reports for diverse audiences.
• Excellent oral communication skills, with ability to convey complex information in an accessible way as well as prepare and give presentations to diverse audiences.
• Demonstrated ability to manage multiple projects, including managing departmental workload in line with the organizational strategy, successfully managing working groups, and proven project management skills.
• Excellent interpersonal skills with a high level of diplomacy and political awareness, and ability to work effectively as a member of the senior management team.
• Sound working knowledge of Windows-based software packages, including Word, Excel, PowerPoint, SharePoint, and Visio as well as online/Internet-based research tools.
• The ability to comprehend and interpret regulatory, legislative, and contractual mandates.
• Experience with managed care, Medicare and federal and/or state regulations and quality improvement.
• High-level of skill in leading interdepartmental and cross-functional strategy development; experience managing professional staff on multiple projects to ensure corporate deadlines and objectives are met. Simultaneously manage multiple projects.
• The utmost integrity in the discreet and confidential handling of confidential materials is necessary.

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