Manager of Clinical 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

The Manager of Clinical Business Process Monitoring leads monitoring and auditing activities of clinical business processes for internal and delegated entities. The Manager of Clinical Business Process Monitoring oversees the core functions of routine clinical monitoring and special audit/monitoring projects, the analysis of findings and presentation of those findings to internal teams and delegated vendors.

In addition, this role provides strategic proposals and careful planning to meet organizational goals, minimize regulatory risk and consider efficiencies within vendor and other special projects as assigned to meet targets and take measurable steps to achieve successful outcomes.

• Oversees day to day monitoring and auditing activities of clinical monitoring team.
• Performs internal clinical monitoring activities and audits and lead special/ad hoc projects as assigned by leadership.
• Plays a critical role in driving the progress of corrective actions. Upon identification of non-compliance, provide oversight of corrective actions plans issued ensuring timely implementation. Provides support to business areas in conducting a root cause analysis and development of effective corrective actions, including guidance on methodology, identification of relevant regulatory requirements and any regulatory compliance context, and compliance review.
• Communicates with compliance functional leaders to monitor, assess and address vendor performance and key outliers that require immediate actionable outcomes.
• Compiles reporting and develop analysis of compliance dashboards to present to department and division leadership.
• Performs data analysis to identify key outliers for process improvement and determine high risk areas of focus for further resolution and successful outcomes.
• Participates in all regulatory and in-house audits and special projects that present high-risk areas for the organization.
• Ensures vendors and special project post activity and analysis translate to measurable, successful outcomes and operational excellence across the board that impacts members, providers, and all internal and external stakeholders.
• Provides coverage for any auditor and any aspect of responsibility (vendor business process monitoring audits, internal, special projects, new focus, ad hoc project management) if/when necessary.
• Contributes to annual work plan aligning with top regulatory issues/focus and create recommendations using advanced critical thinking skill set and outside the box train of thought to mitigate risk.
• Creates analytical summary output reports for meaningful and actionable deficiencies and recommendations cited.
• Oversees staff of 1 or more to provide necessary leadership, training, performance evaluation(s), uphold top quality corporate compliance standards and successful completion of annual work plan
• Assists Department Director in annual risk assessment and Compliance Work Plan development

• Bachelor’s degree required (BSN degree preferred); and
• New York State license as a Registered Nurse with 5-7 years of managed care clinical operations experience, of which at least 3 years need to be in a supervisory or managerial position; or
• Non-Registered Nurse with 10 years of experience in managed care compliance/clinical operations/ or quality management auditing.
• Strong knowledge of utilization review requirements for Medicaid and Medicare products.
• Experience with utilization review requirements for Medicare and Medicaid benefits.
• Experience in delegated vendor oversight, corrective action plan implementation, facilitating and leading cross-functional work groups.
• New York State license as Registered Nurse (preferred)

Professional Competencies

• Strong Analytical and critical thinking skills.
• Strong quantifiable and problem-resolution skills.
• Excellent written, oral and presentation skills with the ability to multitask and effectively prioritize tasks in a fast-paced environment.
• Advanced beginner or higher-level proficiency in Microsoft Suite products: Outlook, MS Teams, SharePoint, PowerPoint, Power BI, Power Automate, Visio, Word, and electronic medical record systems.
• Functional/Technical skills.

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