Clinical Evaluation Nurse Manager: Care Coordination Leader

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

Benefits offered by this job

Referral bonuses

Paid time off (PTO)

Health insurance

Retirement savings plan

Wellness programs

FSAs for healthcare and dependent care

Tuition reimbursement

Career growth opportunities

Internal mobility and CEU credits

Job summary

VNS Health in New York seeks a licensed Nurse for utilization review to assess service requests, determine medical necessity, and coordinate care with physicians, members, and the care team. The role emphasizes cost-effective decisions aligned with policies and regulations.

The position involves telephonic and in-person coordination, adherence to state and federal standards, and collaboration with discharge planners to ensure timely, appropriate care for members.

Qualifications

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

Responsibilities

• Conducts comprehensive review of all components related to requests for services including a clinical record review and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers and other 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.
• 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 patient-focused care plans for safe discharge and transition back to the community.
• Maintains records and documentation per guidelines; supports quality assurance and process improvement.

Education

Associate's Degree in Nursing

Bachelor's Degree or Master’s degree in nursing

Tools

Microsoft Excel

PowerPoint

Word

Job description

VNS Health in New York seeks a licensed Nurse for utilization review to assess service requests, determine medical necessity, and coordinate care with physicians, members, and the care team. The role emphasizes cost-effective decisions aligned with policies and regulations.

The position involves telephonic and in-person coordination, adherence to state and federal standards, and collaboration with discharge planners to ensure timely, appropriate care for members.