Nursing Jobs in Florham Park, NJ
$85,000 - $106,300 / year
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 and 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. 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. 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. 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 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 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. 
$120,000 - $143,000 / year
Join Our Team at Bergen New Bridge Medical Center!** We are dedicated to providing high-quality, compassionate care to our diverse community. As a leading healthcare provider, we offer a supportive and inclusive work environment. If you’re passionate about making a difference and thrive in a collaborative setting, Bergen New Bridge Medical Center is looking for a Nurse Manager. Job Duties Works with Director of Nursing/Associate Director of Nursing to develop and implement goals of assigned units and to evaluate progress toward attainment of goals; acts as liaison between Nursing administration and medical staff. Using available utilization data, works with other Nurse Managers, ADON, and DON to developing staffing plan and schedules for units to maintain appropriate staffing levels and staffing mix; communicates staffing plan to Staffing Coordinator and Nurse Supervisor; ensures adequate staff coverage by reviewing vacation and holiday schedules; approves overtime as necessary and authorizes coverage for absent staff. Selects, hires and supervises staff in the area of responsibility; initiates disciplinary action, including terminations; carries out annual performance appraisals of employees recommending promotions, raises, etc. Comply with contractual agreements and federal guidelines in employee relationships. Ensures safe and professional patient care by enforcing and monitoring compliance to professional standards, identifying clinical and educational needs of staff; recommends methods for improving staff competence and patient care and assists in developing, implementing and evaluating programs. Through meetings, in-services or other established means of communication, provides information to departmental staff for therapeutic and effective patient care management; identifies and puts into place appropriate monitors of patient care delivery. Periodically reviews admission and patient management protocols, discharge criteria and related policies and procedures for compliance with requirements of regulatory agencies; recommends and implements changes as required, making sure information is available to staff in area of responsibility; monitors compliance and reviews with DON, ADONs and ADNs. Oversee the quality assurance/quality improvement programs in area of responsibility, identifying patient care issues, developing QA monitors and ensuring that follow-up actions are implemented. Provides information required for reports on utilization, monitors, credentialing and scheduling as necessary to be compliant with regulatory agency reporting and monitor requirements; prepares reports on service and utilization as required. Assists DON in developing annual budget; monitors budget performance throughout the year to ensure units operate within budget guidelines; works with administration to ensure most efficient and cost-effective allocation and use of resources. Customer Service: respect, flexibility, knowledge, confidence, professionalism, pleasant attitude, patience and helpfulness. All responses should be timely, professional, caring, and respectful in accordance with Customer Service Performance expectations Maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental, and infection control standards. Assesses gaps in policies and procedures and creates necessary policies and procedures to fulfill these gaps. Understands and adheres to the Medical Center’s Code of Conduct. Familiar with the Medical Center’s Mission, Vision, and Values Statements. Other Job Duties Assists management in developing cost accounting methodology and model to enable NBMC to determine costs of nursing care and other direct costs and to provide information for NBMC planning and decisions (e.g., pertinent elements of patient care, labor, non-labor, and indirect allocation). Serves as resource to staff in clinical and management matters. Performs other duties as assigned to support the overall objectives of the department and organization. Position Qualifications Minimum of 3 years of clinical experience in the field required. Supervisory experience preferred. Current New Jersey licensure as RN required. Clinical nursing skills and expertise. Good organizational skills. Good oral and written communication skills. Good interpersonal skills. Speaks, reads and writes English to the extent required by the position. Education BSN required, or proof of current enrollment in an accredited BSN program American Heart Association Basic Life Support certification required. Job Setting/Physical Demands Nursing offices and patient care areas; contact with staff, patients, families. Frequent, prolonged walking, standing and/or sitting. May handle emergency or crisis situations. Salary commensurate with experience within posted range $120,000-$143,000/Year We provide a comprehensive benefits package, including a competitive medical, dental, and vision plans. We prioritize work-life balance with a generous time off policy that includes ample vacation days, personal time, sick leave and nine paid holidays. Additionally, we are committed to the personal and professional growth of our employees, offering robust tuition reimbursement and continuing education programs to help support our employees ongoing development. Please note that selection of the candidate for any position will depend on several factors, including the individual’s educational background, skills, and professional experience. 
