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Registered Nurse Care Manager
2 months ago
VNS Health is seeking a highly skilled Registered Nurse Care Manager to join our team. As a key member of our care management team, you will play a vital role in ensuring our members receive high-quality, cost-effective healthcare services.
Key Responsibilities- Assess Member Needs: Conduct comprehensive reviews of member requests for services, including clinical record reviews and interviews with members, clinical staff, medical providers, and other relevant sources.
- Ensure Medical Necessity: Examine standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care, and lengths of stay.
- Authorize Services: Approve services or consult with medical directors when cases do not meet medical necessity criteria.
- Comply with Regulations: Ensure compliance with state and federal regulatory standards and VNS Health policies and procedures.
- Participate in Case Conferences: Participate in case conferences with management to discuss member cases and develop plans of care.
- Identify Alternative Care Options: Identify opportunities for alternative care options and contribute to the development of patient-focused plans of care to facilitate safe discharges and transitions back into the community.
- Review Covered Services: 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.
- Improve Clinical and Cost-Effective Outcomes: Improve clinical and cost-effective outcomes, such as reduction of hospital admissions and emergency department visits, through ongoing member education, care management, and collaboration with interdisciplinary team members.
- Current License: Current license to practice as a Registered Professional Nurse in New York State required.
- Certified Case Manager: Certified Case Manager preferred.
- Education: Associate's Degree in Nursing or a Master's degree in Occupational Therapy required. Bachelor's Degree or Master's degree in nursing preferred.
- Experience: 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.
- Skills: Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills, and working knowledge of Microsoft Excel, PowerPoint, and Word.
