Registered Nurse (RN) - Nursing Management - Flex

Job TitleAssesses 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 healthcare policies as well as applicable state and federal regulations. Coordinates with 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.What We ProvideReferral bonus opportunitiesGenerous paid time off (PTO), starting at 30 days of paid time off and 9 company holidaysHealth insurance plan for you and your loved ones, Medical, Dental, Vision, Life and DisabilityEmployer-matched retirement saving fundsPersonal and financial wellness programsPre-tax flexible spending accounts (FSAs) for healthcare and dependent careGenerous tuition reimbursement for qualifying degreesOpportunities for professional growth and career advancementInternal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities.What You Will DoConducts 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.Examines standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care and lengths of stay. approves services or consults with medical directors when case does not meet medical necessity criteria.Ensures compliance with state and federal regulatory standards and VNS Health policies and procedures.Participates in case conferences with management.Identifies opportunities for alternative care options and contributes to the development of patient focused plan of care to facilitate a safe discharge and transition back into the community after hospitalization.Reviews covered and coordinated services in accordance with established plan benefits, application of evidenced based medical criteria, and regulatory requirements to ensure appropriate authorization of services and execution of the plan's fiduciary responsibilities.Maintains current knowledge of organizational or state-wide trends that affect member eligibility and the need for issuance of Determination NoticesImproves clinical and cost-effective outcomes such as reduction of hospital admissions and emergency department visits through on-going member education, care management and collaboration with IDT members.Provides input and recommendations for design and development of, processes and procedures for effective member case management, efficient department operations, and excellent customer service.Maintains accurate record of all care management. Verifies that all aspects of the clinical record are in agreement with the member's clinical and functional status. Utilizes VNS Health and state approved assessment and documentation as well as interviews with members, family, and care providers in decision-making.Performs annual clinical co-visits for nurses as well as two initial co-visits during the first six months for new hires as follows: one within first three weeks and a second within the first six months. Provides feedback to therapist and management; For Utilization Management Only:Issues Determinations, Notices of Action, and other forms of communication to members and providers which communicate VNS Health's determinations. Ensures all records/logs related to decision requests, Notices of Action, and other communications required by state or federal regulations are saved in the Utilization Management System.Reviews, evaluates and determines the appropriateness of requests, utilize the most appropriate clinical care guidelines based on clinical practice guidelines. Adheres to all federal and regulatory requirements.Evaluates and analyzes care and utilization trends/issues and identifies opportunities for better coordination of members' care.QualificationsLicenses and Certifications: Current license to practice as a Registered Professional Nurse in New York State required. Associate's Degree in Nursing required. Bachelor's Degree or Master's degree in nursing preferredWork Experience: Minimum two years of experience with strong cost containment /case management background 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. preferred Knowledge of Medicare and Medicaid regulations required 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 For UM Only: Experience must be with a Managed Care Organization or Health Plan. For SelectHealth ETE Only: Experience in Public Health programming, delivery and evaluation preferred Experience working with community-based organizations in underserved communities preferredPay RangeUSD $85,000.00 - USD $106,300.00 /Yr.About UsVNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We're one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.