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. Works under general supervision.
- Authorizes and oversees visits per episode for the optimal utilization that results in the best possible clinical outcomes and efficient use of resources.
- 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).
- Handles managed care escalated clinical authorizations and denials.
- 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.
- Develops, updates, and teaches curriculum, exercises and learning materials for clinicians in conjunction with the Learning & Development and Quality departments to improve on utilization management.
- Educates clinicians to follow best practices in utilization management/care management activities. Identifies areas of concern and works with Education department to revise courses as needed.
- Develops and assigns training activities in conjunction with the Learning & Development and Quality departments, based on individual clinicians’ learning needs and capabilities. Provides direction to staff and Clinical Field Manager, via telephone in response to any situations arising in the field with regard to visit and patient care planning.
- Provides coaching, education, performance evaluation assessments, and counseling and discipline, as needed, to clinicians regarding job performance. Maintains complete and timely documentation of assessment and performance management activity and clinician progress. Evaluates clinician’s performance for annual performance review process, at the request of the Clinical Field Manager.
- Participates in special projects and performs other duties, as needed.
Licensure: License and current registration to practice as a Registered Professional Nurse, Physical Therapist, or Occupational Therapist in NYS required.
Education: Relevant degree needed for professional licensure required.
Certification: Population Care Coordination certification required within one year of job entry date. Care Management, Case Management, OASIS or other applicable certification preferred.
Experience: Minimum two years’ experience as a registered nurse, physical therapist, or occupational therapist 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.