VNS Health
Overview
Assesses member needs and identifies solutions that promote high quality and cost-effective health care services. Manages providers, members, team, or care manager generated requests for medical services and renders clinical determinations in accordance with healthcare policies as well as applicable state and federal regulations. Delivers timely notification detailing clinical decisions. Coordinates with management, subject matter experts, physicians, member representatives, and discharge planners in utilization tracking, care coordination, and monitoring to ensure care is appropriate, timely and cost effective. Works under general supervision.
Responsibilities
Conduct comprehensive review of all components related to requests for services, including clinical record review and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers and other relevant sources as necessary.
Examine standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care and lengths of stay.
Perform prior authorization and concurrent reviews to ensure extended treatment is medically necessary and conducted in the right setting.
Review requests for outpatient and inpatient admission; approve services or consult with medical directors when cases do not meet medical necessity criteria.
Ensure compliance with state and federal regulatory standards and VNS Health policies and procedures.
Participate in case conferences with management and identify opportunities for alternative care options; contribute to the development of patient-focused plans of care to facilitate safe discharge and transition back into the community after hospitalization.
Review covered and coordinated services in accordance with established plan benefits, evidence-based medical criteria, and regulatory requirements to ensure appropriate authorization and execution of the plan's fiduciary responsibilities.
Identify and provide recommendations for improvement regarding department processes and procedures; maintain current knowledge of organizational or state-wide trends affecting member eligibility and determination notices.
Improve clinical and cost-effective outcomes through ongoing member education, care management, and collaboration with IDT members to reduce hospital admissions and emergency department visits.
Provide input and recommendations for design and development of processes and procedures for effective member case management, department operations, and customer service; maintain accurate records of all care management, including written progress notes and verbal communications per guidelines.
Participate in approval for out-of-network services when members receive services outside of the VNS Health network; provide case direction to ensure quality and appropriate service delivery.
Stay current with health plan changes through ongoing training, coaching, and educational materials.
For Care Management Only:
Assess, plan, facilitate and advocate for options and services to effectively manage an individual's health needs; promote quality and cost-effective outcomes at all times.
Provide telephonic case management to members, balancing clinical, social, and environmental concerns; analyze initial health evaluations and comprehensive psychosocial status for case management needs.
Develop, coordinate, and implement care plans addressing specific member/family needs, including transitions between settings of care.
Coordinate with community providers to ensure efficient transitions and delivery of care in home and community settings.
Consult with the member, family, and interdisciplinary team to coordinate treatment plans, education, self-care techniques, and prevention strategies.
Verify that clinical records align with the member's status; use approved assessments and documentation, including member, family, and care provider interviews, in decision-making.
Perform annual clinical co-visits for nurses as well as two initial co-visits during the first six months for new hires (one within first three weeks and a second within the first six months); provide feedback and assist in development of improvement plans.
Qualifications
Licenses and Certifications:
Current license to practice as a Registered Professional Nurse in New York State required.
Education:
Associate's Degree in Nursing required; Bachelor's Degree or Master's degree in nursing preferred.
Work Experience:
Minimum two years of experience with strong cost containment/case management background or two years acute inpatient hospital experience in chronic or complex care required. Must have experience working with LTSS-eligible population; knowledge of Medicare/Medicaid regulations preferred. Excellent organizational, time management, interpersonal, verbal and written communication skills. Working knowledge of Microsoft Excel, PowerPoint, Word; strong typing skills. Knowledge of Medicaid and/or Medicare regulations required. Knowledge of Milliman criteria (MCG) preferred. For UM Only: experience with a Managed Care Organization or Health Plan.
Pay USD $85,000.00 - USD $106,300.00 /Yr.
About Us VNS Health is one of the nation's largest nonprofit home and community-based health care organizations. We have been innovating in health care for more than 130 years, delivering compassionate care and 24/7 resources to the communities we serve.
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Responsibilities
Conduct comprehensive review of all components related to requests for services, including clinical record review and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers and other relevant sources as necessary.
Examine standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care and lengths of stay.
Perform prior authorization and concurrent reviews to ensure extended treatment is medically necessary and conducted in the right setting.
Review requests for outpatient and inpatient admission; approve services or consult with medical directors when cases do not meet medical necessity criteria.
Ensure compliance with state and federal regulatory standards and VNS Health policies and procedures.
Participate in case conferences with management and identify opportunities for alternative care options; contribute to the development of patient-focused plans of care to facilitate safe discharge and transition back into the community after hospitalization.
Review covered and coordinated services in accordance with established plan benefits, evidence-based medical criteria, and regulatory requirements to ensure appropriate authorization and execution of the plan's fiduciary responsibilities.
Identify and provide recommendations for improvement regarding department processes and procedures; maintain current knowledge of organizational or state-wide trends affecting member eligibility and determination notices.
Improve clinical and cost-effective outcomes through ongoing member education, care management, and collaboration with IDT members to reduce hospital admissions and emergency department visits.
Provide input and recommendations for design and development of processes and procedures for effective member case management, department operations, and customer service; maintain accurate records of all care management, including written progress notes and verbal communications per guidelines.
Participate in approval for out-of-network services when members receive services outside of the VNS Health network; provide case direction to ensure quality and appropriate service delivery.
Stay current with health plan changes through ongoing training, coaching, and educational materials.
For Care Management Only:
Assess, plan, facilitate and advocate for options and services to effectively manage an individual's health needs; promote quality and cost-effective outcomes at all times.
Provide telephonic case management to members, balancing clinical, social, and environmental concerns; analyze initial health evaluations and comprehensive psychosocial status for case management needs.
Develop, coordinate, and implement care plans addressing specific member/family needs, including transitions between settings of care.
Coordinate with community providers to ensure efficient transitions and delivery of care in home and community settings.
Consult with the member, family, and interdisciplinary team to coordinate treatment plans, education, self-care techniques, and prevention strategies.
Verify that clinical records align with the member's status; use approved assessments and documentation, including member, family, and care provider interviews, in decision-making.
Perform annual clinical co-visits for nurses as well as two initial co-visits during the first six months for new hires (one within first three weeks and a second within the first six months); provide feedback and assist in development of improvement plans.
Qualifications
Licenses and Certifications:
Current license to practice as a Registered Professional Nurse in New York State required.
Education:
Associate's Degree in Nursing required; Bachelor's Degree or Master's degree in nursing preferred.
Work Experience:
Minimum two years of experience with strong cost containment/case management background or two years acute inpatient hospital experience in chronic or complex care required. Must have experience working with LTSS-eligible population; knowledge of Medicare/Medicaid regulations preferred. Excellent organizational, time management, interpersonal, verbal and written communication skills. Working knowledge of Microsoft Excel, PowerPoint, Word; strong typing skills. Knowledge of Medicaid and/or Medicare regulations required. Knowledge of Milliman criteria (MCG) preferred. For UM Only: experience with a Managed Care Organization or Health Plan.
Pay USD $85,000.00 - USD $106,300.00 /Yr.
About Us VNS Health is one of the nation's largest nonprofit home and community-based health care organizations. We have been innovating in health care for more than 130 years, delivering compassionate care and 24/7 resources to the communities we serve.
#J-18808-Ljbffr