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 VNSNY CHOICE Health policies as well as applicable state and federal regulations. Delivers timely notification detailing VNSNY CHOICE clinical decisions. Coordinates with VNSNY CHOICE Care and Utilization 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.
- 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.
- Verifies that all aspects of the clinical record are in agreement with the member’s clinical and functional status. Utilizes VNSNY and state approved assessment and documentation as well as interviews with members, family, and care providers in decision-making.
- 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 VNSNY CHOICE policies and procedures.
- Actively 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.
- Issues Determinations, Notices of Action, and other forms of communication to members and providers which communicate VNSNY CHOICE’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.
Licensure: Current license to practice as a Registered Professional Nurse in New York State required. Certified Case Manager preferred.
Education: Bachelor’s degree or Master’s degree in nursing preferred.
Experience: Minimum two years of utilization review experience with strong cost containment /case management background at a Managed Care Organization or Health Plan required 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 preferred. 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.
The Visiting Nurse Service of New York (VNSNY) is the nation's largest not-for-profit home- and community-based health care organization, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Countries. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost effective healthcare in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, members, and clients from before birth to the end of life. Each day, more than 13,000 VNSNY employees - including nurses, rehabilitation therapists, social workers, other allied professionals, and paraprofessionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to more than 44,000 patients and members, helping them to live the best lives possible in their homes and communities.