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

Position Overview

Under the supervision of the Senior Director, the Partnership in Care (PIC) Operations Manager will oversee the day-to-day operations of the department including direct oversight of the eligibility and retention team, ensuring the department meets the defined operational and regulatory requirements. The Operations manager will ensure the department maintains adherence with all audits, quality, and compliance activities.

As a member of the PIC Department Leadership, the Operations Manager will develop and monitor timely and accurate reports for the care management team. This position will also monitor HIV viral load data acquisition from lab vendors, hospitals, CBOs, and any other agency to ensure accurate and timely delivery. The PIC Operations Manager will liaise closely with analytics, MIS team, Network Relations, Quality Management, Claims and Compliance to ensure all projects and processes are adhered to and completed as required.

• Oversee Partnership in Care operations including eligibility, retention, and compliance activities
• Ensure compliance with Federal, State, and city regulations as they relate to Partnership in Care including Medicare Model of Care and HIV SNP model contract
• Manage and oversee key performance improvement projects that impact the department's outcomes and compliance with local, Federal, and State regulations and guidelines
• Manage and prepare for compliance audits such as Article 44, IPRO reviews, etc.
• Monitor and improve data collection of HIV viral load lab test results across major laboratory vendors, hospitals, community providers and other agencies as required
• Develop and monitor timely, accurate, and complete reports on operations of PIC department
• Track and develop action plans for correction of identified issues and long-term solutions
• Supports clinical, quality, cost management, reporting, and strategic initiatives and provides project management as necessary
• Monitors disenrollment and tracks cause with development of strategy for member retention
• Monitors and assist with annual recertification process as needed
• Monitors high utilizers and members with frequent hospital admissions to develop strategies to engage members in outpatient, non-urgent care
• Identifies member appropriate for Advanced Care Management activities and ensures documentation compliance as determined by the AIDS Institute
• Assists with MetroPlusHealth HIV SNP conversion process by identifying CBOs for collaboration
• Offer analytic assistance to Care Management team as required.

• Bachelor's degree from an accredited college or university in a healthcare-related field is required.
• Five (5) plus years of relevant managed care and operations management experience required.
• Minimum three (3) years of health plan project management experience preferred
• Requires strong analytic and strategic planning skills.
• Must be able to successfully facilitate sound business objectives within highly regulated industry.
• Experience managing projects for external customers and developing effective customer relationships desired.
• Extensive working knowledge of management techniques as applied to projects.
• Experience assembling and motivating cross functional teams to meet requirements.
• Creative problem-solving skills, a win-win mentality.
• Excellent negotiation skills
• Demonstrate skills in Operations and Project Management tools including Microsoft Excel.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Written/Oral Communications

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