VNS Health
Overview
Oversees the utilization of medical care and treatment of VNS MSO members and provides direction and guidance to the staff to assure appropriate and expedient decision-making with attention to quality of care. Consults and cooperates with internal and external partners. Works under general direction.
What We Provide
Referral bonus opportunities
Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
Employer-matched retirement saving funds
Personal and financial wellness programs
Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
Generous tuition reimbursement for qualifying degrees
Opportunities for professional growth and career advancement
Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities
What You Wil Do
Provides medical determinations for purposes of Utilization Management (UM), initial and internal appeals decisions. This includes review of clinical information provided against evidence-based guidelines, ensure plan compliance with regulatory requirements, focus on improving quality of care, and support departments of VNS MSO that request medical review services.
Reviews internal staff or external provider rationales related to coverage decisions.
Reviews relevant medical records and clinical information on file in the context of performing clinical reviews. (e.g.: inpatient hospital records, outpatient professional notes, Letters of Medical Necessity (LOMN), assessment reports, etc.)
Utilizes appropriate, evidence-based guidelines for reviews and organizational determination such as. (e.g.: Medicare NCDs, LCDs, Medicaid guidelines, MCG guidelines, VNS Health policies, etc.)
Provides clinical case summary and determination rationale and member letter verbiage as appropriate.
Ensures decisions deadlines are met and adhere by business goals and ensure compliance.
Completes and documents peer-to-peer consultation according to policy through completion of any finalized decision.
Participates in interdisciplinary rounds.
Reviews Quality of Care (QOC) concerns, care records and QOC summary. Assist with case summary, case level assignment and recommended next steps.
Participates in special projects and performs other duties as assigned.
Qualifications Licenses and Certifications:
Licensed to practice medicine in state of residence required
Licensed to practice medicine in New York State preferred
Specialty Board Certified or Eligible required
Board Certification in Internal or Family Medicine preferred
Certification in Geriatric Care preferred
Education:
Medical Degree required
Work Experience:
Minimum five years of experience in clinical medicine, including three years in managed care, and application of evidence based medical necessity criteria and CMS guidance required
Prior experience in geriatric medicine preferred
Prior experience in Utilization Management (UM) and/or a Medical Services Organization preferred
Demonstrated strong knowledge of Medicare and Medicaid regulatory and reporting requirements required
Strong communication and influential skills required
Exceptional critical thinking and decision-making skills preferred
Pay Range USD $172,900.00 - USD $230,500.00 /Yr.
About Us VNS Health
is one of the nation's largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us - we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 "neighbors" who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.
#J-18808-Ljbffr
What We Provide
Referral bonus opportunities
Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
Employer-matched retirement saving funds
Personal and financial wellness programs
Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
Generous tuition reimbursement for qualifying degrees
Opportunities for professional growth and career advancement
Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities
What You Wil Do
Provides medical determinations for purposes of Utilization Management (UM), initial and internal appeals decisions. This includes review of clinical information provided against evidence-based guidelines, ensure plan compliance with regulatory requirements, focus on improving quality of care, and support departments of VNS MSO that request medical review services.
Reviews internal staff or external provider rationales related to coverage decisions.
Reviews relevant medical records and clinical information on file in the context of performing clinical reviews. (e.g.: inpatient hospital records, outpatient professional notes, Letters of Medical Necessity (LOMN), assessment reports, etc.)
Utilizes appropriate, evidence-based guidelines for reviews and organizational determination such as. (e.g.: Medicare NCDs, LCDs, Medicaid guidelines, MCG guidelines, VNS Health policies, etc.)
Provides clinical case summary and determination rationale and member letter verbiage as appropriate.
Ensures decisions deadlines are met and adhere by business goals and ensure compliance.
Completes and documents peer-to-peer consultation according to policy through completion of any finalized decision.
Participates in interdisciplinary rounds.
Reviews Quality of Care (QOC) concerns, care records and QOC summary. Assist with case summary, case level assignment and recommended next steps.
Participates in special projects and performs other duties as assigned.
Qualifications Licenses and Certifications:
Licensed to practice medicine in state of residence required
Licensed to practice medicine in New York State preferred
Specialty Board Certified or Eligible required
Board Certification in Internal or Family Medicine preferred
Certification in Geriatric Care preferred
Education:
Medical Degree required
Work Experience:
Minimum five years of experience in clinical medicine, including three years in managed care, and application of evidence based medical necessity criteria and CMS guidance required
Prior experience in geriatric medicine preferred
Prior experience in Utilization Management (UM) and/or a Medical Services Organization preferred
Demonstrated strong knowledge of Medicare and Medicaid regulatory and reporting requirements required
Strong communication and influential skills required
Exceptional critical thinking and decision-making skills preferred
Pay Range USD $172,900.00 - USD $230,500.00 /Yr.
About Us VNS Health
is one of the nation's largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us - we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 "neighbors" who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.
#J-18808-Ljbffr