Overview

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 healthcare policies as well as applicable state and federal regulations. Delivers timely notification detailing clinical decisions. 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. This position is mostly remote (minimum of 1x per month in the office)

Compensation Range:$85,000.00 - $106,300.00 Annual

What We Provide

• Referral bonus opportunities     
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays   
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability    
• Employer-matched retirement saving funds   
• Personal and financial wellness programs    
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care     
• Generous tuition reimbursement for qualifying degrees   
• Opportunities for professional growth and career advancement    
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities     

What You Will Do

• Conducts 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. Performs prior authorization and concurrent reviews to ensure extended treatment is medically necessary and being conducted in the right setting. Reviews requests for outpatient and inpatient admission; 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.
• Identifies and provides recommendations for improvement regarding department processes and procedures.
• Maintains current knowledge of organizational or state-wide trends that affect member eligibility and the need for issuance of Determination Notices
• Improves 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. Maintains written progress notes and verbal communications according to program guidelines.
• Participates in approval for out-of-network services when member receives services outside of VNS Health network services.
• Provides case direction and assistance ensuring quality and appropriate service delivery.
• Keeps current with all health plan changes and updates through on-going training, coaching and educational materials.
• Assesses, plans, facilitates and advocates for options and services to effectively manage an individual’s health needs. Promotes quality and cost-effective outcomes at all times.
• Provides telephonic case management to members, balancing clinical, social, and environmental concerns.
• Provides analysis of initial health evaluation and comprehensive assessment of the member/family psychosocial status and case management needs. Participates in the development, coordination and implementation of the care plan to address specific needs of the member/family including thorough transitions between settings of care.
• Coordinates with community providers to ensure efficient and effective transitions and delivery of care in the home and community.
• Consults with the member, family, and members of the inter-disciplinary team to coordinate the treatment plan, education, self-care techniques and prevention strategies.
• 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; assists in development of plans to address improvement needs as appropriate.

Qualifications

Licenses and Certifications:
Current license to practice as a Registered Professional Nurse

Education:
Associate's Degree in Nursing or a Master’s degree required
Bachelor's Degree or Master’s degree in nursing preferred

Work 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