Medical Implementation Manager

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.

Job Overview

Under the supervision of the Sr. Director of Behavioral Health or Vice President of Clinical Services, with a dotted line to the SWAT Director of Implementation, the Medical Management Implementation Manager is part of a cross-functional/department SWAT team that ensures regulatory required system changes are implemented including post-production audits. The Medical Management Implementation Manager will also be responsible for implementing any company strategic initiatives that involve medical management scope of work.This position is responsible for assuring all impacted Medical Management policies, procedures and staff workflows are revised including communication of implementation status and resolution of barriers to medical management leadership. The Medical Management Implementation Manager must provide subject matter input that assures system changes result in accurate impacted claims, benefits, utilization and care management requirements, and member handbook and provider guidance. The SWAT team ensures the requirements are understood across impacted departments and new enhanced processes are developed. Lastly, this position will be responsible for the medical management oversight of the implementations from start to completion including comprehensive testing.

• Key stakeholder in SWAT team for behavioral health, pharmacy, and physical health benefit configuration, provider data, internal and external communications, accurate claims payment, and assuring positive impact on clinical, quality, and operational excellence.
• Responsible to ensure accuracy and timeliness of the full project cycle of regulatory implementations from beginning through completion, including comprehensive testing for medical management.
• Responsible for developing medical management staff communications on project/implementation impact and provide input to the Training & Development team for any required staff training.
• Responsible for understanding implementation requirements and ensuring team is actively tracking the project to completion through QuickBase.
• Liaise with the Regulatory and Compliance department as it relates to product readiness reviews, implementation, and ongoing oversight of activities.
• Collaborate with departments across the MetroPlusHealth organization to continually understand and optimize performance.
• Serve as subject matter expert in all benefit, behavioral health rate, care management and utilization management functional areas in Regulatory implementations.
• Knowledge and analysis of complex Product benefit and system configurations.
• Provide oversight on benefit implementations ensuring proper configuration.
• Provide input to required changes and impact to implementation to MetroPlusHealth vendors.
• Provide behavioral health, pharmacy and physical health subject matter expertise to the SWAT team through collaboration with various medical management leadership input.
• Monitor project progress at each stage of the process. Identify risks and escalate gaps to Medical Management leadership, SWAT Director of Implementation, and Regulatory and Compliance teams.
• Ensures compliance with Federal and State regulations as they relate to behavioral health and physical health.

• Bachelor's degree required
• Minimum seven (7) years of experience working in Health Care and experience with NY State sponsored programs and CMS regulations in managed care.
• Knowledge of medical, behavioral health and pharmacy benefit structures for various lines of business.
• Knowledge of utilization and care management workflows.
• Project Management skills preferred.
• Working knowledge of Product Department, implementations, system transformation and operational aspects of health care.
• Skills in Microsoft Excel, PowerPoint, and Word are required

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