Medical Care Nurse Specialist

21 hours ago

Fairview, 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 in Fairview, New Jersey.

Job Summary:

We are looking for a highly motivated and detail-oriented Registered Nurse to resolve grievances, appeals, and external reviews for our VNS Health Plans product lines. The ideal candidate will have a strong background in healthcare, excellent communication skills, and the ability to work independently.

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 resolve grievances and appeals.
  • Coordinate external case reviews, preparing and submitting documentation according to regulatory requirements.
  • Collaborate with professionals, health plan departments, and third-party administrators to facilitate resolution of individual grievances and appeals.
  • Provide input and recommendations for policy design and development to improve department operations and customer service.
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, with knowledge of Microsoft Office (Word and Excel).
What We Offer:
  • Generous paid time off (PTO) and 9 company holidays.
  • Health insurance plan for you and your loved ones, including medical, dental, vision, life, and disability coverage.
  • Employer-matched retirement savings funds.
  • Personal and financial wellness programs.
  • Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care.
  • Generous tuition reimbursement for qualifying degrees.

VNS Health is one of the nation's largest nonprofit home and community-based health care organizations, innovating in health care for over 125 years. We help people live, age, and heal where they feel most comfortable, in their own homes, connected to their family and community.

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