**Care Manager

4 days ago

Cliffside Park, New Jersey, United States VNS Health Full time
About the Role

VNS Health is seeking a skilled Care Manager - Registered Nurse to join our team. As a key member of our healthcare team, you will play a vital role in ensuring our patients receive the highest quality care.

Key Responsibilities
  • Conduct comprehensive reviews of patient requests for services, including clinical record reviews and interviews with patients, clinical staff, medical providers, and other relevant sources.
  • Examine standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, and lengths of stay.
  • Perform prior authorization and concurrent reviews to ensure extended treatment is medically necessary and being conducted in the right setting.
  • Review requests for outpatient and inpatient admission, and approve services or consult with medical directors when cases do not meet medical necessity criteria.
  • Ensure compliance with state and federal regulatory standards and VNS Health policies and procedures.
  • Participate in case conferences with management and identify opportunities for alternative care options.
  • Contribute to the development of patient-focused plans of care to facilitate safe discharges and transitions back into the community.
  • Review covered and coordinated services in accordance with established plan benefits, application of evidence-based medical criteria, and regulatory requirements.
  • Identify and provide recommendations for improvement regarding department processes and procedures.
  • Maintain current knowledge of organizational or state-wide trends that affect member eligibility and the need for issuance of Determination Notices.
  • Improve clinical and cost-effective outcomes through ongoing member education, care management, and collaboration with interdisciplinary team members.
Requirements
  • Current license to practice as a Registered Professional Nurse in New York State.
  • Minimum two years of experience with strong cost containment/case management background or two years acute inpatient hospital experience in chronic or complex care.
  • Knowledge of Medicare and Medicaid regulations.
  • Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills.
  • Working knowledge of Microsoft Excel, PowerPoint, and Word, and strong typing skills.
About VNS Health

VNS Health is one of the nation's largest nonprofit home and community-based health care organizations. Our commitment to health and well-being drives us to provide innovative care solutions that meet the diverse and complex needs of our patients.

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