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Clinical Case Manager
2 months ago
VNS Health is seeking a skilled Registered Nurse to join our team as a Case Manager in Acute Care Case Management. This role requires a strong clinical background and excellent communication skills to assess member needs and identify solutions that promote high-quality and cost-effective healthcare services.
Key Responsibilities:- Assess member needs and develop comprehensive care plans to ensure timely and cost-effective healthcare services.
- Manage providers, members, and team-generated requests for medical services, rendering clinical determinations in accordance with healthcare policies and regulations.
- Deliver timely notification detailing clinical decisions and coordinate with management, subject matter experts, physicians, and discharge planners to ensure care is appropriate, timely, and cost-effective.
- Conduct comprehensive reviews of requests for services, including clinical record reviews and interviews with members, clinical staff, medical providers, and other relevant sources.
- Examine standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care, and lengths of stay.
- Perform prior authorization and concurrent reviews to ensure extended treatment is medically necessary and being conducted in the right setting.
- Ensure compliance with state and federal regulatory standards and VNS Health policies and procedures.
- Participate in case conferences with management and identify opportunities for alternative care options.
- Contribute to the development of patient-focused plans of care to facilitate safe discharges and transitions back into the community after hospitalization.
- Review covered and coordinated services in accordance with established plan benefits, application of evidence-based medical criteria, and regulatory requirements.
- Identify and provide recommendations for improvement regarding department processes and procedures.
- Maintain current knowledge of organizational or state-wide trends that affect member eligibility and the need for issuance of Determination Notices.
- Improve clinical and cost-effective outcomes through ongoing member education, care management, and collaboration with interdisciplinary team members.
- Provide input and recommendations for design and development of processes and procedures for effective member case management, efficient department operations, and excellent customer service.
- Maintain accurate records of all care management, including written progress notes and verbal communications.
- Participate in approval for out-of-network services when members receive services outside of VNS Health network services.
- Provide case direction and assistance to ensure quality and appropriate service delivery.
- Keep current with all health plan changes and updates through ongoing training, coaching, and educational materials.
Requirements:
- Current license to practice as a Registered Professional Nurse in New York State required.
- Certified Case Manager preferred.
- Minimum two years of experience with strong cost containment/case management background.
About VNS Health:
VNS Health is a leading healthcare organization dedicated to providing high-quality, patient-centered care to our members. We are committed to excellence in healthcare and strive to make a positive impact in the lives of our patients and their families.