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RN, Utilization Management, Health Plans

Overview

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 Counties. For 125 years, VNSNY has been committed to meeting the health care needs of New Yorkers with compassionate, high-quality home health care. 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 48,000 patients and members, helping them to live the best lives possible in their homes and communities.

Responsibilities

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. Works under general supervision.

Licensure: Current license to practice as a Registered Professional Nurse in New York State required. Certified Case Manager preferred.

Education: Bachelor&rsquot;s degree or Master&rsquot;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.