AVP Care Coordination

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.

• 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.
  • Performance Excellence: Establish clear departmental goals, key performance indicators (KPIs), and robust data‑driven metrics to track success across all care coordination functions. Regularly report progress to executive leadership.
  • Culture of
    
    Collaboration:
    
    Foster a positive, high‑performing team culture that values collaboration, innovation, continuous improvement, and patient‑centered care. Mentor and empower staff to achieve their full potential.
  • Organizational Advocacy: Champion the critical role of care coordination in optimizing patient outcomes, resource utilization, and financial performance. Actively participate in organizational leadership discussions to advocate for resources and support.
  • Utilization Review Committee: Establish committee to ensure CMS and regulatory compliance. Develop and maintain a UM plan to guide the team with detailed processes and procedures. Attend and contribute to the UR committee meetings.
• Utilization Review (UR):
  • 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.
  • Concurrent Review: Oversee the concurrent review process, monitoring patient progress, verifying continued need for services, and facilitating timely discharge planning.
  • Post‑Acute Care Coordination: Collaborate with post‑acute care providers to ensure smooth transitions of care, prevent readmissions, and optimize patient outcomes.
• Denials Management & Appeals:
  • 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.
  • Appeals Expertise: Oversee the preparation and submission of comprehensive appeals, ensuring accuracy, clinical validity, and adherence to payer requirements. Monitor appeal outcomes and adjust strategies as needed.
  • Data‑Driven Improvement: Utilize denials data to identify trends, prioritize improvement efforts, and negotiate with payers for fair reimbursement.
  • Physician Advisor
    
    Collaboration:
    
    Collaborate with the physician advisor (PA) group and leader to ensure processes and goals are aligned; including peer‑to‑peer results, observation rates, observation conversion rates, medical necessity outreach, and…