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**Care Manager

2 months ago

Ridgefield, 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; approve services or consult with medical directors when case does 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.
  • Identify opportunities for alternative care options and contribute to the development of patient-focused plans of care to facilitate safe discharge and transition 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.
  • Provide clinical and programmatic support to the ETE grant project.
  • Coordinate and participate in ETE conference calls with designated AIDS Centers (DAC) sites.
  • Participate in weekly outreach team case conferences.
  • Coordinate sharing of information between subcontractor Community-Based Organizations (CBOs), DAC, and internal staff at VNS Health.
  • Participate in special projects and perform other duties as assigned.
Requirements
  • Current license to practice as a Registered Professional Nurse or an Occupational Therapist in New York State required.
  • Certified Case Manager preferred.
  • For SelectHealth ETE Only: Nurse Practitioner (NP) certification with background or degree in Public Health preferred.
  • Education: Associate's Degree in Nursing or a Master's degree in Occupational Therapy 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, PowerPoint, and Word and strong typing skills required.
  • Knowledge of Medicaid and/or Medicare regulations required.
  • Knowledge of Milliman criteria (MCG) preferred.
  • For SelectHealth ETE Only: Experience in Public Health programming, delivery, and evaluation preferred.
  • Experience working with community-based organizations in underserved communities preferred.