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Registered Nurse Case Manager
2 months ago
VNS Health is seeking a skilled Registered Nurse Case Manager to join our team in a nursing role in New Jersey.
Job SummaryWe are looking for a highly motivated and experienced Registered Nurse Case Manager to work in our Acute Care Case Management department. The successful candidate will be responsible for assessing member needs, identifying solutions that promote high-quality and cost-effective healthcare services, and managing providers, members, and team-generated requests for medical services.
Key Responsibilities- Assess member needs and identify solutions that promote high-quality and cost-effective healthcare services.
- Manage providers, members, and team-generated requests for medical services, rendering clinical determinations in accordance with healthcare policies and applicable state and federal regulations.
- Deliver timely notification detailing clinical decisions, coordinating with management, subject matter experts, physicians, member representatives, and discharge planners to ensure care is appropriate, timely, and cost-effective.
- Work under general supervision, conducting comprehensive reviews of all components related to requests for services, including clinical record reviews and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers, and other relevant sources as necessary.
- Examine standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care, and lengths of stay.
- Perform prior authorization and concurrent reviews to ensure extended treatment is medically necessary and being conducted in the right setting.
- Ensure compliance with state and federal regulatory standards and VNS Health policies and procedures.
- Participate in case conferences with management.
- Identify opportunities for alternative care options and contribute to the development of patient-focused plans of care to facilitate safe discharges and transitions back into the community after hospitalization.
- Review covered and coordinated services in accordance with established plan benefits, application of evidence-based medical criteria, and regulatory requirements to ensure appropriate authorization of services and execution of the plan's fiduciary responsibilities.
- 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 such as reduction of hospital admissions and emergency department visits through ongoing member education, care management, and collaboration with IDT members.
- Provide input and recommendations for design and development of processes and procedures for effective member case management, efficient department operations, and excellent customer service.
- Maintain accurate records of all care management, including written progress notes and verbal communications according to program guidelines.
- Participate in approval for out-of-network services when members receive services outside of VNS Health network services.
- Provide case direction and assistance ensuring quality and appropriate service delivery.
- Keep current with all health plan changes and updates through ongoing training, coaching, and educational materials.
- Current license to practice as a Registered Professional Nurse or an Occupational Therapist in New York State.
- Certified Case Manager certification preferred.
- 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.
- 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, PowerPoint, and Word and strong typing skills required.
