Clinical Evaluation Manager, Utilization Management

VNS Health; New York (NY); On-site; USD 85,000 - 106,300; Full time

Benefits offered by this job

Referral bonus opportunities

Generous paid time off (30 days and 9 holidays)

Health insurance for employees and family

Employer-matched retirement savings

Personal financial wellness programs

Tuition reimbursement for qualifying degrees

Opportunities for career advancement

Job summary

VNS Health is looking for a Registered Professional Nurse to provide comprehensive care management. You will review service requests and ensure compliance with healthcare regulations while coordinating with various healthcare professionals.

With a focus on quality and cost-effective care, this role requires at least two years of experience and a nursing degree, prioritizing excellent organizational and communication skills. Join VNS Health and help support a vast network of patients!

Qualifications

• Current license to practice as a Registered Professional Nurse in New York State required.
• Certified Case Manager preferred.
• Minimum two years' experience in case management or acute inpatient hospital management required.

Responsibilities

• Conduct comprehensive reviews of service requests and clinical records.
• Examine standards to ensure medical necessity of treatment.
• Ensure compliance with health plan policies and state regulations.
• Participate in case conferences with management.
• Identify alternative care options and develop patient care plans.
• Maintain accurate records and participate in service approvals.

Skills

Cost containment background

Case management

Knowledge of Medicare and Medicaid

Organizational skills

Communication skills

Microsoft Excel

Microsoft PowerPoint

Microsoft Word

Typing skills

Education

Associate's Degree in Nursing

Bachelor's or Master's Degree in Nursing

Job description

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.

MLTC experience required.

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 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 Will Do:

• Conducts comprehensive review of all components related to requests for services which includes a clinical record review and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers and other relevant sources as necessary.
• Examines standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care and lengths of stay. Performs prior authorization and concurrent reviews to ensure extended treatment is medically necessary and being conducted in the right setting. Reviews requests for outpatient and inpatient admission; approves services or consults with medical directors when case does not meet medical necessity criteria.
• Ensures compliance with state and federal regulatory standards and VNS Health policies and procedures.
• Participates in case conferences with management.
• Identifies opportunities for alternative care options and contributes to the development of patient focused plan of care to facilitate a safe discharge and transition back into the community after hospitalization.
• Reviews covered and coordinated services in accordance with established plan benefits, application of evidenced based medical criteria, and regulatory requirements to ensure appropriate authorization of services and execution of the plan's fiduciary responsibilities.
• Identifies and provides recommendations for improvement regarding department processes and procedures.
• Maintains current knowledge of organizational or state‑wide trends that affect member eligibility and the need for issuance of Determination Notices
• Improves clinical and cost‑effective outcomes such as reduction of hospital admissions and emergency department visits through on‑going member education, care management and collaboration with IDT members.
• Provides input and recommendations for design and development of, processes and procedures for effective member case management, efficient department operations, and excellent customer service.
• Maintains accurate record of all care management. Maintains written progress notes and verbal communications according to program guidelines.
• Participates in approval for out‑of‑network services when member receives services outside of VNS Health network services.
• Provides case direction and assistance ensuring quality and appropriate service delivery.
• Keeps current with all health plan changes and updates through on‑going training, coaching and educational materials.
• For Utilization Management Only:
• Issues Determinations, Notices of Action, and other forms of communication to members and providers which communicate VNS Health's determinations. Ensures all records/logs related to decision requests, Notices of Action, and other communications required by state or federal regulations are saved in the Utilization Management System.
• Reviews, evaluates and determines the appropriateness of requests, utilize the most appropriate clinical care guidelines based on clinical practice guidelines. Adheres to all federal and regulatory requirements.
• Evaluates and analyzes care and utilization trends/issues and identifies opportunities for better coordination of members' care.
• Weekend rotation.

Licenses and Certifications

Current license to practice as a Registered Professional Nurse in New York State required. Certified Case Manager preferred.

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 and qualifications demonstrating knowledge of working with the LTSS eligible population. Knowledge of Medicare and Medicaid regulations required. Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills. Working knowledge of Microsoft Excel, Power‑Point, and Word and strong typing skills required. Knowledge of Medicaid and/or Medicare regulations required. Knowledge of Milliman criteria (MCG) preferred. For UM Only: Experience must be with a Managed Care Organization or Health Plan.

Pay Range

USD $85,000.00 - USD $106,300.00 /Yr.

About Us

VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We're one of the largest nonprofit home‑ and community‑based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.