Clinical Utilization & Care Coordination Manager

VNS Health; New York (NY); On-site; USD 61,992 - 77,145; Full time

Benefits offered by this job

Referral bonus opportunities

30 days PTO + 9 holidays

Health insurance for you and family

Employer-matched retirement savings

Job summary

VNS Health is seeking a care management professional in New York to assess member needs, coordinate services, and render clinical determinations in line with policies and regulations. The role includes prior authorizations, discharge planning, and collaboration with multi-disciplinary teams to ensure timely, cost-effective care.

Responsibilities cover comprehensive reviews, adherence to medical necessity criteria, and documentation while maintaining regulatory compliance.

Qualifications

• Current license to practice as a Registered Nurse (RN) or an Occupational Therapist (OT) or Physical Therapist (PT) in New York State is required.
• Certified Case Manager is preferred.
• Education: an Associate's Degree in Nursing or a Master’s degree in Occupational Therapy is required; a Bachelor's or Master's in nursing is preferred.
• Minimum two years of experience with strong cost containment/case management background or two years acute inpatient hospital experience in chronic or complex care is required.
• Knowledge of Medicare/Medicaid regulations and Microsoft Excel, PowerPoint, and Word is required.

Responsibilities

• Conducts comprehensive review of all components related to requests for services including clinical record review and interviews with members and health care providers.
• Examines medical necessity and appropriateness of admissions, treatment, level of care and lengths of stay; performs prior authorizations and concurrent reviews.
• Ensures compliance with state and federal regulatory standards and VNS Health policies.
• Participates in case conferences with management.
• Promotes safe discharge planning and transitions back into the community.
• Maintains accurate records and provides documentation per guidelines.
• Coordinates care management and utilization management activities to ensure cost-effective outcomes.

Skills

Cost containment

Case management

Interpersonal skills

Time management

Verbal and written communication

Education

Associate's Degree in Nursing

Master’s in Occupational Therapy

Bachelor's or Master’s in Nursing

Tools

Excel

PowerPoint

Word

Job description

VNS Health is seeking a care management professional in New York to assess member needs, coordinate services, and render clinical determinations in line with policies and regulations. The role includes prior authorizations, discharge planning, and collaboration with multi-disciplinary teams to ensure timely, cost-effective care.

Responsibilities cover comprehensive reviews, adherence to medical necessity criteria, and documentation while maintaining regulatory compliance.