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.
- 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 VNSNY 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 VNSNY 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.
- Participates in special projects and performs other duties as assigned.
- Issues Determinations, Notices of Action, and other forms of communication to members and providers which communicate VNSNY’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.
Licensure:Current license to practice as a an Occupational Therapist in New York State required. Certified Case Manager preferred.
For SelectHealth ETE Only: Nurse Practitioner (NP) certification with background or degree in Public Health preferred.
Education: Masters degree in Occupational Therapy required. Bachelor’s degree or Master’s degree in nursing preferred.
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 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.
For UM Only: Experience must be with a Managed Care Organization or Health Plan.
For SelectHealth ETE Only: Experience in Public Health programming, delivery and evaluation preferred. Experience working with community-based organizations in underserved communities preferred.
The Visiting Nurse Service of New York (VNSNY) is one of the nation's largest not-for-profit home- and community-based health care organizations, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Counties. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost-effective health care in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, health plan members, and clients from before birth to the end of life. On any given day, VNSNY employees - including nurses, rehabilitation therapists, social workers, home health aides and other professionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to approximately 40,000 individuals in our care helping them to live the best lives possible in their homes and communities.