RN Manager/Supervisor Full-time
VNS Health

Clinical Evaluation Manager, Registered Nurse

VNS Health New York, NY, US
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.



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.
  • Participates in special projects and performs other duties as assigned.

Qualifications

Licenses and Certifications:

  • Current license to practice as a Registered Professional Nurse in New York State required
  • Certified Case Manager preferred


Education:

  • Associate's Degree in Nursing 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
     

Pay Range

USD $85,000.00 - USD $106,300.00 /Yr.
About Us

VNS 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.

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Initiates and maintains written (including clinical and progress notes) and verbal communications with team members and management to assure optimal patient/client care. • Participates in the orientation of selected staff through ‘buddy system’ field observation of staff and feedback to appropriate staff involved in orientation process. • Participates in selected student programs by providing guidance, training and mentoring to students. • Provides nursing care in accordance with VNS Health policies, practices, procedures and Standards of Nursing Practice, which may require standing, stooping, sitting, crouching, bending and stretching to deliver patient/client care. • Transports and utilizes required medical equipment and other supplies using VNS Health designated/supplied carrying case weighing approximately 25 – 30 lbs. to and from patient/client homes/care facilities. • Travels to patient/clients’ homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options to deliver direct care to the patient/client. • Follows work procedures in relation to established workflows. • Maintains productivity sufficient to meet VNS Health goals. • Assumes responsibility for personal professional growth through attendance at in-services, training, continued formal education and select journal readership. • Performs other related duties and participates in special project, as assigned. • For CHHA and Hospice Only • Establishes, implements, and revises a plan of care with input from appropriate multidisciplinary health team members (i.e., physician, OT, PT, SW, SLP, family members, caregivers, HHAs, etc.) based on goals mutually acceptable to the patient and significant others. Ensures that services follow the plan of care by ongoing assessment, planning, coordination, counseling, teaching and supervision of the delivery of care to meet the needs of the patient. • Oversees/supervises the care provided to the patient by Licensed Practical Nurses and Paraprofessionals through regular home visits in compliance with regulatory and VNS Health requirements. Assesses the patient’s condition, monitors the effect of the care plans on the patient/family health status, informs physician and other team members of changes in the client's needs and updates the plan of treatment, as needed. • Manages, plans, coordinates and executes the patient’s safe discharge from service. Ensures that physician’s orders, discharge summary and communication to team members, patient and family members adhere to VNS Health and regulatory requirements. • Communicates and consults with patient’s MD and follows-up on problematic situations affecting care such as abnormal clinical findings, medication discrepancies, or other factors that impact patient’s ability to comply with the plan of care. Manages and coordinates all aspects of assigned caseload. • Assists patients with activities of daily living, which may require positioning, moving, transferring and lifting patients of varying weights and physical conditions, with and without assistance and as appropriate, from family members and/or paraprofessionals. • For NFP Only • Establishes, implements, and revises a plan of care with input from the client and from appropriate multidisciplinary health team members (i.e., social worker, physician) based on goals mutually acceptable to the client. Ensures that services follow the plan of care by ongoing assessment, planning, coordination, counseling, teaching, and evaluation of the delivery of care to meet the needs of the client. • Manages, plans, coordinates and executes the client’s safe discharge from service. Ensures that discharge summary and communication to team members, patient and family members adhere to VNS Health and regulatory requirements. • Maintains a flexible work schedule to meet clients needs. • Participates in all required NFP training sessions. • Participates in special projects and performs other duties as assigned. Qualifications Licenses and Certifications: License and current registration to practice as a registered professional nurse in New York State required Valid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needs. For Hospice Only: Wound Care Certification required or willingness to obtain within one (1) year of hire preferred Certification in Hospice and Palliative Care Nursing preferred Education: Degree in Nursing from an approved program required Bachelor's Degree NFP Only- Nursing required Work Experience: Experience for CHHA: Minimum of one year of experience in a medical/surgical environment required Experience for Hospice: Minimum of one year of clinical nursing experience, including at least six months of Hospice, or Med/Surg or ICU or Emergency Dep’t or Home care, Palliative Care, Oncology or Long Term Care experience required Experience for NFP: Minimum of one year of recent experience in maternal/child health required Demonstrated basic computer skills required Pay Range per Visit: If you are applying to the per diem per visit version of this job, the hiring range is as follows: $78.64- $123.20 per visit. Pay Range USD $118,942.00 - USD $152,717.00 /Yr. About Us VNS 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.