Staff Nurse I

3 days ago

Cliffside Park, New Jersey, United States VNS Health Full time
Job Description

VNS Health is seeking a skilled Registered Nurse to join our team as a Case Manager. As a key member of our healthcare team, you will be responsible for assessing member needs and identifying solutions that promote high-quality and cost-effective healthcare services.

Key Responsibilities:
  • Assess member needs and develop comprehensive care plans to ensure timely and cost-effective healthcare services.
  • Manage providers, members, and team-generated requests for medical services, rendering clinical determinations in accordance with healthcare policies and regulations.
  • Deliver timely notification detailing clinical decisions and coordinate with management, subject matter experts, physicians, and member representatives to ensure care is appropriate, timely, and cost-effective.
  • Work under general supervision to ensure compliance with state and federal regulations and VNS Health policies and procedures.
  • Participate in case conferences with management and identify opportunities for alternative care options to facilitate safe discharge and transition back into the community.
  • 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 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 to ensure quality and appropriate service delivery.
  • Keep current with all health plan changes and updates through ongoing training, coaching, and educational materials.
Requirements:
  • Current license to practice as a Registered Professional Nurse in New York State required.
  • Certified Case Manager 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.
  • Must have experience and qualifications demonstrating knowledge of working with the LTSS eligible population.
  • 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.
What We Offer:
  • Guaranteed hours.
  • 401k retirement plan.
  • Employee assistance programs.
  • Dental benefits.
  • Vision benefits.
  • License and certification reimbursement.
  • Life insurance.
  • Discount program.
  • Holiday pay.
  • Continuing education.
  • Wellness and fitness programs.
  • Mileage reimbursement.
  • Medical benefits.

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