Claims examiner Jobs in Yonkers, NY

Vice President Of Quality Management

The Vice President of Quality Management is responsible for the strategic development and implementation of Saint Joseph's Medical Center's Patient Safety and Quality Program. The quality program includes initiatives to maximize quality, improve patient safety, and mitigate risk.

In collaboration with the SJMC Senior Leadership Team, the Vice President of Quality and Risk functions as the Patient Safety Officer to develop and prioritize organizational quality initiatives to ensure that patient safety is integrated into all initiatives, whether clinical, operational, or related to improving the patient experience.

This position coordinates external regulatory surveys and data reporting to ensure organizational performance meets desired objectives.

Duties and responsibilities include:

• Serving as Patient Safety Officer.
• Promoting organizational understanding, communication, and coordination of Quality Management programs through the established quality committee structure, creating targeted workgroups and ensuring state goals and objectives are met.
• Maintaining and establishing indicators for monitoring and evaluating the quality and appropriateness of care and services.
• Assessing continuous improvement in monitored indicator activities.
• Monitoring member satisfaction and directing initiatives for improvement while evaluating the effectiveness of interventions across the continuum of care.
• Serving as the primary contact for regulatory agencies and maintaining awareness of regulatory requirements and updates.
• Developing and implementing programs to improve safety and decrease risk.
• Providing primary support to the Risk Management Program, including claims management, insurance management, and regulatory reporting.
• Providing oversight of the Corporate Compliance Program, ensuring adherence to federal and state compliance requirements.
• Serving as a role model and leader to colleagues and staff throughout the organization.
• Representing the organization internally and externally as required.

Risk management responsibilities include:

1. Working with leadership in organizational operations, quality, etc.
2. Serving on the Audit Committee, Quality Assessment and Performance Improvement Subcommittee, Performance Improvement Safety Council, and Radiation Safety Committee.
3. Having authority to retain, direct, and approve compensation of defense counsel.
4. Conducting analyses to identify patterns that could result in compensable events.
5. Responding to the needs of the Medical Staff and department heads regarding Risk Management.
6. Developing and implementing facility policies and procedures affecting liability exposure.
7. Selecting and utilizing consulting services, brokers, carriers, and related resources.
8. Providing summary reports for incidents, claims, reserves, and claim payments.
9. Complying with state and federal laws, regulations, and reporting requirements related to patient care, patient safety, and investigations.
10. Reviewing contracts and agreements for compliance with Saint Joseph's Medical Center insurance specifications.
11. Working with defense counsel by providing required information, data, materials, and policies for active and potential claims.
12. Reporting and preparing written reports for the New York Patient Occurrence Reporting and Tracking System (NYPORTS).
13. Preparing reports and providing NYPORTS data for the Quality Assessment and Performance Improvement Subcommittee.
14. Reviewing occurrence reports and preparing summaries for the Environment of Care and Audit Committees.
15. Providing in-service education for facility staff.
16. Reviewing medical records for areas of potential liability exposure.
17. Reviewing occurrence reports and other reporting tools for patterns and trends that could result in compensable events.
18. Managing the Institutional Review Board (IRB) as it relates to facility policies and legal requirements.
19. Developing and implementing facility policies and procedures to meet legal requirements.
20. Procuring outside loss prevention services.

Claims management duties include:

1. Managing reporting procedures, system maintenance, claim investigations, reserve establishment, legal counsel selection, claimant communications, settlements, and actuarial services.
2. Ensuring compliance with Medicare and Medicaid regulations related to claim settlements.
3. Managing federal Section 111 SCHIP reporting for Medicare Secondary Payer requirements.
4. Reporting claims information to the Audit Committee.
5. Directing investigative activities.
6. Directing claims handling and defense preparation with attorneys and insurers.
7. Projecting future costs related to losses, insurance, and other risk management activities.
8. Managing and resolving claims within the self-insured program in collaboration with the Chief Financial Officer, President & CEO, and Board of Trustees when applicable.

Risk financing responsibilities include:

1. Maintaining familiarity with insurance markets.
2. Planning, coordinating, and administering a comprehensive insurance program, including purchasing, consulting, self-insurance administration, and claims handling (excluding Workers' Compensation).
3. Preparing data for brokers and carriers and managing insurance claims through settlement.
4. Preparing specifications for competitive bidding and negotiating insurance coverage, premiums, and services.
5. Recommending changes in risk control and financing based on operational changes.
6. Reporting projected insurance costs to the Finance Department.

Corporate compliance duties include:

1. Logging corporate compliance issues.
2. Maintaining records of in-service attendance and compliance issues.
3. Preparing reports for regulatory agencies, the Board of Trustees, and others as required.
4. Monitoring changes in compliance laws and regulations and reporting significant changes to management.
5. Providing compliance education to hospital staff.
6. Serving as liaison between legal counsel and auditors.
7. Chairing the Compliance Committee.
8. Providing education to the Compliance Committee.
9. Coordinating reports presented to the Compliance Committee.
10. Assisting in developing the SJMC Audit Log for the Compliance Committee and Audit Committee.
11. Participating in the GNYHA Compliance Group to remain current on healthcare compliance issues.

Key responsibility areas include:

• Clinical Risk Management
• Loss Prevention
• Claims Management
• Risk Financing
• Corporate Compliance

Mission

The above duties and responsibilities reflect the Mission of Saint Joseph's Medical Center and Nursing Home.

Saint Joseph's is a Catholic healthcare facility sponsored by the Sisters of Charity of St. Vincent de Paul of New York. With a commitment to the community, the organization strives for excellence in healthcare within an atmosphere of support, dignity, respect, and compassion.

Corporate Compliance

Employees must read and understand the comprehensive Code of Conduct and carry out the legal and ethical requirements necessary to fulfill their obligations to Saint Joseph's Medical Center while adhering to all federal and state requirements.

Physical demands include:

• Walking
• Writing
• Bending
• Good general health
• Occasional lifting of light objects

Qualifications/Education

• MHA; MBA; MPA; and RN
• Clinical background required to conduct root cause analyses and evaluate clinical operations
• Master's degree in a healthcare-related field
• Specialty certification preferred
• Progressive leadership experience

Experience

1. Minimum of five (5) years of experience in a hospital setting.
2. Experience with insurance applications and purchasing.
3. Experience with network computer systems.
4. Familiarity with clinical settings.
5. Expertise in management and operational assessment.

Special skills include:

1. Strong written and verbal communication skills.
2. Moderate computer skills.

Licenses/Registrations/Certifications

• Registered Professional Nurse (NYS)