Care Management Clinical Evaluations Lead

VNS Health; New York (NY); On-site; USD 85,000 - 106,000; Full time

Benefits offered by this job

Wellness programs

Professional growth opportunities

Internal mobility

Interdisciplinary network

Job summary

VNS Health is seeking a qualified care management professional in New York to assess member needs, review requests, and ensure clinical decisions are compliant with state and federal regulations. You will conduct comprehensive clinical reviews, perform prior and concurrent authorizations, and coordinate with care teams to support safe discharge and transition back into the community.

The role requires NY licensure as RN or OT, CCM preferred, with at least two years in case management or acute

Qualifications

• Current NY license to practice as a Registered Professional Nurse or an Occupational Therapist; CCM preferred.
• Associate's Degree in Nursing required; Bachelor's or Master's in nursing preferred.
• Minimum two years of cost containment/case management experience or two years acute inpatient hospital experience in chronic/complex care.

Responsibilities

• Reviews requests for services with clinical record review and interviews with members and staff.
• Performs prior authorization and concurrent reviews to ensure medical necessity and appropriate setting.
• Approves services or discusses with medical directors when criteria are not met.
• Participates in case conferences and contributes to care plans for safe discharge and community transition.
• Maintains up-to-date records and documentation according to guidelines.
• Coordinates with LTSS providers to ensure smooth transitions and delivery of care.

Skills

Interpersonal skills

Verbal and written communication

Microsoft Excel

PowerPoint

Word

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Master's Degree in Nursing

Tools

Microsoft Excel

PowerPoint

Word

Job description

VNS Health is seeking a qualified care management professional in New York to assess member needs, review requests, and ensure clinical decisions are compliant with state and federal regulations. You will conduct comprehensive clinical reviews, perform prior and concurrent authorizations, and coordinate with care teams to support safe discharge and transition back into the community.

The role requires NY licensure as RN or OT, CCM preferred, with at least two years in case management or acute