Senior Clinical Evaluation & Care Manager

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

Job summary

VNS Health is seeking a licensed professional to assess member needs and grant medically necessary health services. You will manage provider coordination, conduct reviews, and ensure compliance with Medicaid/Medicare regulations.

The role requires licensure in New York and at least two years of cost containment or case management experience, with proficiency in Excel, PowerPoint, and Word. You will support care transitions and collaborate with multi-disciplinary teams.

Qualifications

• Current license to practice as a Registered Nurse in New York State or an Occupational Therapist license is required.
• Minimum two years of cost containment / case management background or two years acute inpatient hospital experience in chronic or complex care.
• Knowledge of Medicare and Medicaid regulations is required.
• Working knowledge of Microsoft Excel, PowerPoint, and Word; strong typing skills.

Responsibilities

• Reviews requests for services to determine medical necessity and appropriateness, including clinical record reviews and interviews.
• Performs prior authorization and concurrent reviews to ensure services are medically necessary and appropriately set.
• Maintains accurate care management records, written progress notes, and documentation per guidelines.
• Participates in case conferences with management and coordinates with IDT members for care planning.
• Reviews plans and coordinates transitions from hospital to home or community settings to ensure safe discharge.

Skills

Cost containment

Case management

Medicare/Medicaid knowledge

Excel/PowerPoint/Word

Education

Associate's Degree in Nursing

Master's Degree in Occupational Therapy

Bachelor's or Master's in Nursing preferred

Job description

VNS Health is seeking a licensed professional to assess member needs and grant medically necessary health services. You will manage provider coordination, conduct reviews, and ensure compliance with Medicaid/Medicare regulations.

The role requires licensure in New York and at least two years of cost containment or case management experience, with proficiency in Excel, PowerPoint, and Word. You will support care transitions and collaborate with multi-disciplinary teams.