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Clinical Care Manager, RN

Overview

Oversees and directs clinical utilization, authorization, and care management for field staff and/or managed care organizations to ensure effective utilization and care 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. Utilizes evidence based practices to care manage individuals to prevent hospitalization occurrences. Manages relationships with individuals in order to prevent untoward outcomes. Manages clinical and financial risk of value based contracts.


Responsibilities

  • Authorizes and oversees visits per episode for the optimal utilization that results in the best possible clinical outcomes

    and efficient use of resource

  • Works directly with the patient, via various forms of communication, texting, virtual visits, and telephone, to achieve

    patient stated goals

  • Analyzes utilization to ensure visits are made according to episode utilization guidelines and clinical outcomes best

    practices.  Develops/revises utilization policies and practices based on analysis of past practices to improve utilization

  • Applies clinical experience and judgment to the utilization management/care management activities

  • Addresses payor authorizations/reauthorizations 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 manager

    in 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, and visit threshold reports.  Establishes on-going dialogue with

    payor case managers and provider disciplines (e.g., nurses, physical therapist, occupational therapist, speech therapy,

    social worker)

  • Directs field 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

  CA2020


Qualifications
  •  License and current registration to practice as a Registered Professional Nurse in NYS required

  • Associate’s degree in nursing

  • Population Care Coordination certification required within one year of job entry date.  Care Management, Case Management, OASIS or other applicable certification preferred.

  • Minimum two years’ experience as a registered nurse required.  Utilization management managed care experience preferred/care management.  Proficiency in Microsoft Office applications required.  Demonstrated analytical skills required


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ABOUT US

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.