The UAS Assessment RN assess member needs and identifies solutions that promote high quality and cost effective health care services. Manages requests for services from providers, members, and care management team and renders clinical determinations in accordance with VNSNY CHOICE policies as well as applicable state and federal regulations. Delivers timely notification detailing VNSNY CHOICE clinical decisions. Coordinates with VNSNY CHOICE team, subject matter experts, physicians, member representatives, and discharge planners 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.
- Utilizes VNSNY and state approved assessment questionnaire, guidelines and documentation as well as interviews with members, family, and care providers in decision-making.
- Performs in-home assessment for members who have identified significant changes in condition since last in-home assessment; provides comprehensive review and determination of member’s needs, including completion of UAS assessment questionnaire, tasking tool, and a projected service plan. Visits include all areas serviced by VNSNY CHOICE including upstate and downstate counties.
- Performs in-home assessment on members to determine the appropriate service plan, including completion of UAS assessment questionnaire, tasking tool, and a projected service plan. Visits include all areas serviced by VNSNY CHOICE.
- Examines standards and criteria to ensure medical necessity and appropriateness of service, admissions, and lengths of stay. Performs prior authorization and concurrent reviews to ensure service and covered benefit is medically necessary and being conducted in the right setting.
- 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 or care management experience at a Managed Care Organization or Health Plan, or discharge planning preferred.
- Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills required. Demonstrated strong relationship management skills, including a high degree of psychological sophistication and non-aggressive assertiveness required.
- Demonstrated successful conflict management skills and negotiation of win-win solutions required. Working knowledge of Microsoft Excel, Power-Point, and Word 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.