Medical Care Specialist

3 weeks ago


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

VNS Health is seeking a skilled Registered Nurse (RN) to join our team as a Clinic Utilization Reviewer. This role is ideal for a dedicated healthcare professional who is passionate about delivering high-quality patient care and ensuring regulatory compliance.

Key Responsibilities:
  • Resolve grievances, appeals, and external reviews for VNS Health Plans product lines, including Managed Long Term Care (MLTC), Medicare Advantage (MA), and Select Health.
  • Ensure timely and accurate resolution of grievances and appeals, meeting regulatory requirements and organizational standards.
  • Collaborate with healthcare professionals, health plan departments, and external stakeholders to investigate and resolve individual grievances and appeals.
  • Develop and maintain current knowledge of state and federal regulatory requirements related to grievances and appeals.
  • Conduct reviews of requests for prior authorization of health services and prepare written responses consistent with regulatory requirements.
  • Coordinate external case reviews, including preparing and submitting documentation according to regulatory requirements.
Requirements:
  • License and current registration to practice as a registered professional nurse in New York State.
  • Minimum three years progressive professional experience in healthcare, including a minimum of two years in a grievance and appeals or related area.
  • Proficient computer and typing skills and knowledge of Microsoft Office (Word and Excel).
What We Offer:
  • Generous paid time off (PTO) and 9 company holidays.
  • Health insurance plan for you and your loved ones.
  • Employer-matched retirement saving funds.
  • Personal and financial wellness programs.
  • Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care.
  • Generous tuition reimbursement for qualifying degrees.

VNS Health is a nonprofit home and community-based health care organization dedicated to delivering compassionate care and unparalleled expertise to our neighbors. We offer a full range of health care services, solutions, and health plans designed to simplify the health care experience and meet the diverse and complex needs of those we serve.



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