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Clinical Assessment Nurse
2 months ago
Evaluates patient requirements and determines strategies that enhance high-quality and cost-efficient healthcare services. Oversees service requests from healthcare providers, patients, and care management teams, making clinical judgments in line with VNS Health's policies as well as relevant state and federal regulations. Provides prompt notifications outlining VNS Health's clinical decisions. Collaborates with the VNS Health team, subject matter experts, healthcare professionals, patient representatives, and discharge planners to ensure care is suitable, timely, and economical. Operates under general supervision.
Compensation:$85,000 - $106,300.00 Annually
Benefits Offered
- Referral bonus opportunities
- Comprehensive paid time off (PTO), starting at 30 days of paid leave and 9 company holidays
- Health insurance options for you and your family, including Medical, Dental, Vision, Life, and Disability coverage
- Employer-matched retirement savings plans
- Personal and financial wellness initiatives
- Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
- Generous tuition reimbursement for eligible educational programs
- Opportunities for professional development and career progression
- Internal mobility, extensive tuition reimbursement, CEU credits, and advancement pathways
- Collaborative network of professionals through the VNS Health Social Services Community
Responsibilities
- Conducts thorough evaluations of all aspects related to service requests, including clinical record assessments and interviews with patients, clinical personnel, medical providers, paraprofessional staff, caregivers, and other pertinent sources as necessary.
- Utilizes VNS Health's and state-approved assessment tools, guidelines, and documentation alongside interviews with patients, families, and care providers in decision-making processes.
- Performs in-home evaluations for patients who have experienced significant changes in their condition since the last assessment; delivers a comprehensive review and determination of the patient's needs, including the completion of assessment questionnaires and service planning tools. Visits encompass all regions served by VNS Health.
- Evaluates in-home assessments on patients to establish the appropriate service plan, including the completion of assessment questionnaires and service planning tools. Visits cover all areas serviced by VNS Health.
- Reviews standards and criteria to ensure medical necessity and appropriateness of services, admissions, and lengths of stay. Conducts prior authorization and concurrent reviews to confirm that services and covered benefits are medically necessary and conducted in the appropriate setting.
- Applies effective review standards, service determinations, resource management, education, and related interventions to enhance the quality of care and/or life, ensure cost-effective medical outcomes, prevent hospitalizations when feasible, avert complications for patients under care when possible, provide continuity of care, and guarantee appropriate levels of care are received.
- Ensures adherence to state and federal regulatory standards and VNS Health policies and procedures.
- Identifies opportunities for alternative care solutions and contributes to the development of a member-centered service plan.
- Issues determination letters, including Notices of Action, and other communications to patients and providers.
- Maintains current knowledge of organizational or statewide trends affecting patient eligibility and the necessity for issuing Notices of Action.
- Ensures all records/logs related to decision requests, Notices of Action, and other communications mandated by state or federal regulations are documented and retained in the patient's record.
- Evaluates and analyzes utilization trends/issues and identifies opportunities for improved coordination of patient services.
- Collaborates with other departments, such as Care Management, Legal Affairs, Grievance and Appeals, Compliance, Membership Eligibility Unit, and Quality as necessary.
- Participates in approvals for out-of-network services when patients receive care outside of VNS Health's network.
- Stays updated with all health plan changes and updates through ongoing training, coaching, and educational resources.
- Engages in special projects and performs additional duties as assigned.
License/Certifications
- Current license to practice as a Registered Professional Nurse in New York State is required. Certification as a Case Manager is preferred.
Education
- Bachelor's or Master's degree in nursing is preferred.
Work Experience
- A minimum of two years of clinical assessment, homecare, or hospital experience is required. Excellent organizational and time management skills, interpersonal skills, and verbal and written communication skills are essential.
- Demonstrated strong relationship management skills, including a high degree of psychological sophistication and non-aggressive assertiveness are required.
- Proven conflict management skills and the ability to negotiate "win-win" solutions are required. Proficiency in Microsoft Excel, PowerPoint, and Word is required.
- Knowledge of Medicaid and/or Medicare regulations is required. Familiarity with UAS-NY is preferred.
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