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's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Director of Business Process Monitoring provides leadership, direction and oversight of the corporate cross-functional medical management and claims business process monitoring teams. This position will be responsible for maintaining a constant state of readiness for medical management and claims related regulatory audits and for keeping the organization current with changes to standards for medical management and claims regulatory requirements. This position will function as the subject matter expert for medical management and claims compliance with regulatory requirements.

• Oversee MetroPlusHealth Plan's compliance with medical management and claims regulatory requirements, directing, engaging, and supporting internal departments to meet NYS DOH and CMS medical management and claims processing regulatory requirements.
• Provide support to achieve strategic and operational goals through review and development of member and provider materials, manuals, policies, procedures, documents, and reports.
• Lead the implementation of medical management and claims processing regulatory policy corrections, additions, and clarifications to existing requirements.
• Develop audit tools and reports. Provide training to audit team members on use of tools and completion of reports.
• Plan, direct and execute audits of internal operational areas to ensure compliance with plan policies and procedures, as well as regulatory requirements.
• Plan, direct and conduct post-audit conferences with operational area leaders and make recommendations to bring deficiencies into compliance with regulatory standards.
• Plan, direct and execute delegated vendor audits to ensure compliance with contractual and regulatory requirements.
• Provide oversight of the development and review of the Utilization Management letter templates to ensure compliance with regulatory requirements.
• Provide oversight of the development and review of the EOP and EOB templates to ensure compliance with regulatory requirements.
• Provide oversight of vendor Utilization Management letter templates to ensure compliance with regulatory requirements.
• Provide oversight of vendor EOP and EOB templates to ensure compliance with regulatory requirements.
• Provide day to day oversight and direction to all direct reports. Ensure corporate, departmental, and budgetary goals are met.
• Direct supervision of direct and indirect reports, supporting their development of professional skills through coaching and training and use of MetroPlusHealth Plan opportunities.
• Direct supervision of medical management and claims processing regulatory metrics and monitoring.
• Establish and engage direct and indirect reports into collaborative working relationships with MetroPlus Health Plan departments to address regulatory compliance activities.
• Direct development, revisions, and integration of policies, processes, procedures, operational tracking, and transition to electronic formats to address compliance with the Plan's operations, delegation, accreditation, and medical management and claims processing regulatory requirements.
• Provide oversight, assistance through problem solving and information to the teams to address issues as a result of the audits, requests for information and to adhere to established accreditation and regulatory timeframes.
• Direct the development and ongoing maintenance of electronic files for all regulatory audit documents needed to support regulatory compliance.

• Bachelor's Degree required, Master's Degree in Health Care, Business, or related field preferred.
• 5-8 years' experience in managed care operations, health care administration or quality improvement with direct oversight and leadership experience in auditing, delegation oversight, regulatory requirements specifically CMS and NYS DOH.
• Proven leadership as evidenced by 5-8 years' experience in leading and directing teams with divergent experience and goals from different departments, including managing multiple projects with various priorities and deadlines.
• Strong change leadership, management, facilitation skills within an operation that addresses complex relationships and multiple stakeholders with conflicting goals and priorities.
• Outstanding interpersonal and human relations skills; ability to organize and lead work teams, establish and maintain strong positive working relationships.
• Strong problem solving, analytical, negotiating, and independent decision-making skills paired with strong attention to detail.
• Ability to make independent decisions with Plan department leaders, external vendors, regulators, and accreditation bodies.
• Exceptional and creative troubleshooting skills with a keen ability to expediently analyze situations and implement process improvements and effective solutions.
• Proficient in understanding and speaking the English language, with strong written communication verbal in person and telephonically and presentation skills.
• Demonstrates ability to manage conflict, build, support, mentor teams and the ability to recognize and address positive behaviors that contribute to successful achievement of Plan goals.
• Ability to use software to produce required documentation and reports.

Licensure and/or Certification Required

• Compliance Certification preferred (CHC, CCEP)

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

#Li-Hybrid