Oversees and directs clinical utilization/authorization for field staff and/or managed care organizations to ensure effective utilization/care and case rate management as defined by inter professional best practices. Ensures clear and appropriate visit utilization using evidence-based practices to provide positive clinical outcomes and efficient use of resources. Identifies and addresses inter-professional performance issues related to utilization management among staff and provides individualized performance evaluation assessments to clinical leadership and staff.
- Authorizes and oversees visit case rates for the optimal utilization that results in the best possible clinical outcomes and efficient use of resources. Directs clinician to obtain consultations, e.g., wound consults and community based social work referrals as required.
Analyzes utilization to ensure visits are made according to case rate utilization guidelines and clinical outcomes best practices. Develops/revises utilization/case rate policies and practices based on analysis of past practices to improve utilization and patient outcomes.
Addresses payor authorizations/reauthorizations and care management within established time frames which includes, but is not limited to, reviewing clinical reports of providers for relevant patient data, communicating patient condition to payor case managerin a manner that is focused and reflects knowledge/understanding of patient condition/progress, and negotiating authorizations consistent with clinical data.
Ensures appropriate utilization of home health care and other resources for optimal, cost effective care and services by reviewing clinical reports, DME/supply requisitions, visit threshold reports and directing referrals to Clinical Support Managers and community resources. Establishes on-going dialogue with payor case managers and provider disciplines (e.g., nurses, physical therapists, occupational therapists, speech language pathologists, social workers and dietitians).
Develops a series of utilization management/case rate reports that summarize program performance and clinical outcomes. Monitors results and directs staff to take actions that address issues and improve performance, including
changing plans of care and notifies payor case manager of significant changes in patient condition. Evaluates performance and reports assessments to clinical management and works with them to set accountability mechanisms and long-term correction standards.
Handles managed care escalated clinical authorizations and denials.
Consults with and educates the patients and family regarding the treatment plan, self-care techniques and prevention strategies.
- Licensure: Current registration to practice as a Licensed social worker in New York Stated preferred.
- Certification: Care Management or Case Management certification required within one year of job entry date.
- Education: Bachelor’s degree in Social Work required. Master’s Degree in Social Work preferred.
- Experience: Minimum one year social work experience in a health care setting required Utilization management and/or managed care experience preferred. Proficiency in Microsoft Office applications required. Demonstrated analytical skills required.
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.