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Nurse Utilization Review Specialist

2 months ago

Fairview, New Jersey, United States VNS Health Full time
About the Role

VNS Health is seeking a skilled Nurse Utilization Review Specialist to join our team. As a key member of our quality improvement team, you will play a critical role in ensuring the highest level of patient care and satisfaction.

Key Responsibilities
  • Conduct thorough clinical assessments, including medication reconciliations, post-discharge transitions of care, and emergency department assessments.
  • Collaborate with healthcare programs to ensure compliance with regulatory requirements, including DOH, CMS, and NCQA.
  • Develop and implement quality improvement initiatives to enhance patient outcomes, satisfaction, and cost-effectiveness.
  • Conduct clinical reviews with primary care providers and specialists to address non-adherence and clinical diagnosis for HEDIS/QARR exclusion.
  • Participate in and lead improvement teams and projects to drive performance improvement, measurement, and documentation.
  • Perform audits on medical records and provide guidance to primary care providers on VNS Health Medical Record Documentation Standards.
  • Develop and implement tools and methodologies for concurrent and retrospective patient care review.
  • Perform utilization and quality assessment reviews to ensure compliance with federal and state regulatory requirements.
  • Develop action plans and recommendations for quality improvement initiatives.
  • Participate in site visits and investigations related to patient complaints and incidents.
Requirements
  • License and current registration to practice as a Registered Professional Nurse in New York State.
  • Minimum of three years quality improvement experience in a health plan or healthcare setting.
  • Excellent oral, written, and interpersonal communication skills, including group facilitation skills.
  • Knowledge of basic performance improvement tools and methodologies.
About VNS Health

VNS Health is a nonprofit home and community-based healthcare organization dedicated to delivering compassionate care and unparalleled expertise to our patients. With a commitment to health and well-being, we strive to simplify the healthcare experience and meet the diverse needs of those we serve.