Medical Care Specialist
3 weeks ago
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.
- 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).
- 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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Wound Care Specialist
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