Medical Care Nurse Specialist

11 hours ago


Hoboken, New Jersey, United States VNS Health Full time
Job Title: Medical Care Nurse

VNS Health is seeking a skilled Registered Nurse to join our team as a Clinic Utilization Review professional. This role is responsible for resolving grievances, appeals, and external reviews for our Managed Long Term Care, Medicare Advantage, and Select Health product lines.

Key Responsibilities:
  • Investigate and review routine and complex situations, analyzing and solving problems related to medical necessity, quality of care, and long-term services and supports.
  • Consult with members, families, providers, and health plan departments as necessary to ensure accurate and timely follow-up.
  • Coordinate the resolution of grievances and appeals according to defined processes and procedures, ensuring regulatory requirements are met.
  • Review covered and coordinated services in accordance with established plan benefits, medical criteria, and regulatory requirements.
  • Collaborate with professionals, health plan departments, and third-party administrators to investigate and facilitate resolution of individual grievances and appeals.
Requirements:
  • License and current registration to practice as a registered professional nurse in New York State.
  • Minimum three years of progressive professional experience in healthcare, including a minimum of two years in a grievance and appeals or related area.
  • Proficient computer and typing skills, and knowledge of Microsoft Office (Word and Excel).
About VNS Health:

VNS Health is one of the nation's largest nonprofit home and community-based health care organizations. We innovate in healthcare for over 125 years, driven by our commitment to health and well-being. Our team delivers compassionate care, unparalleled expertise, and 24/7 solutions and resources to our neighbors who look to us for care.

We offer a range of health care services, solutions, and health plans designed to simplify the healthcare experience and meet the diverse and complex needs of those we serve in New York and beyond.



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