Posted:
5/28/2024, 5:00:00 PM
Location(s):
New York, New York, United States ⋅ New York, United States
Experience Level(s):
Senior
Field(s):
Medical, Clinical & Veterinary
What We Provide:
What You Will Do
Provides oversight of VNS Health Plans clinical components for utilization review and decision making.
Leads in establishing medical policies for VNS Health Plans; collaborates in the design and implementation of advanced care/case management strategies; and communicates, with providers to ensure effective quality care is being provided as needed.
Reviews utilization and care management data; identifies trends and needs of the program population; and collaborates with Medical Management leadership to develop and implement plans to meet needs.
Provides guidance and consultative services to Utilization Management (UM) and Care Management (CM) staff on issues relating to clinical services, case management, condition management, and health risk assessments. Develops solutions for complex cases, reviews prior authorizations/denial of services, and grievances and appeals. Participates in weekly care management/UM rounds for products, as applicable. Performs audits of other UM/CM physician peer reviewers.
Provides leadership to the Quality Improvement Program and advises Health Plan leadership on the adoption and enforcement of polices concerning medical services for Health Plan members.
Ensures compliance with relevant and applicable federal, state and local laws and regulations. Works with Compliance and Special Investigation Unit on issues related to Fraud, Waste, and Abuse of Medicare/Medicaid services.
Ensures that Health Plan and program guidelines are adhered to in measuring adequacy, appropriateness and effectiveness of plan of care; assists in evaluating program and member service policies and procedures to help develop ways to enhance effective delivery of care and member/provider satisfaction.
Acts as a representative of the VNS Health Plans and an advocate for the community through liaison, lecturing and promotional activities. Attends external meetings, seminars, and conferences to promote sharing of expertise and educate consumers and external providers regarding the service model.
Performs clinical reviews and conducts peer to peer meetings with in-network and out of network providers.
#LI-Hybrid
Licenses and Certifications:
Licensed to practice medicine in New York State required
Multi-state licensure preferred
Board Certification in internal or family medicine preferred
Certification in Geriatric Care preferred
Education:
Medical Degree, required
Work Experience:
Minimum five years of experience in clinical medicine, including three years in managed care, and application of evidence based medical necessity criteria and CMS guidance required
Prior experience in geriatric medicine preferred
Prior experience in a Medical Services Organization preferred
Demonstrated strong knowledge of Medicare and Medicaid regulatory and reporting requirements required
Strong communication and influential skills required
Exceptional leadership, critical thinking and decision-making skills preferred
Website: https://vnshealth.org/
Headquarter Location: New York, New York, United States
Employee Count: 10001+
Year Founded: 1893
IPO Status: Private
Industries: Charity ⋅ Health Care ⋅ Home Health Care ⋅ Non Profit