Medical Care Nurse Specialist

7 days ago

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

VNS Health is seeking a skilled Medical Care Nurse to join our team in Edgewater, New Jersey.

About the Role:

We are looking for a highly motivated and experienced Medical Care Nurse to work in our Utilization Review department. As a Medical Care Nurse, you will be responsible for resolving grievances, appeals, and external reviews for our Managed Long Term Care (MLTC), Medicare Advantage (MA), and Select Health product lines.

Key Responsibilities:
  • Investigate and review routine and complex situations and underlying issues, 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 identify and communicate key points from details.
  • Investigate and coordinate the resolution of routine and complex grievances and appeals according to defined processes and procedures, ensuring required timeframes and regulatory requirements are met.
  • Review covered and coordinated services in accordance with established plan benefits, application of medical criteria, and regulatory requirements to ensure appropriate appeal resolution and execution of the plan's fiduciary responsibilities.
  • Conduct review of requests for prior authorization of health services, as required in certain product lines, and prepare written responses consistent with regulatory requirements.
  • Coordinate external case reviews requested by enrollees, including preparing and submitting documentation according to regulatory requirements and tracking external reviews throughout the process.
Requirements:
  • License and current registration to practice as a registered professional nurse in New York State required.
  • Minimum three years progressive professional experience in healthcare, including a minimum of two years in a grievance and appeals or related area such as medical or utilization management required.
  • Proficient verbal/written communication skills required.
  • Proficient computer and typing skills and knowledge of Microsoft Office (Word and Excel) required.
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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