RN Care Manager, Medicare

Overview

Assesses member needs and identifies solutions that promote high quality and cost-effective health care services. Manages providers, members, team, or care manager generated requests for medical services and renders clinical determinations in accordance with healthcare policies as well as applicable state and federal regulations. Delivers timely notification detailing clinical decisions. Coordinates with management, subject matter experts, physicians, member representatives, and discharge planners in utilization tracking, care coordination, and monitoring to ensure care is appropriate, timely and cost effective. Works under general supervision.

What We Provide

Referral bonus opportunities

Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays

Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability

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

Opportunities for professional growth and career advancement

Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do

Conducts comprehensive review of all components related to requests for services which includes a clinical record review and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers and other relevant sources as necessary.

Examines standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care and lengths of stay. Performs prior authorization and concurrent reviews to ensure extended treatment is medically necessary and being conducted in the right setting. Reviews requests for outpatient and inpatient admission; approves services or consults with medical directors when case does not meet medical necessity criteria.

Ensures compliance with state and federal regulatory standards and VNS Health policies and procedures.

Participates in case conferences with management.

Identifies opportunities for alternative care options and contributes to the development of patient focused plan of care to facilitate a safe discharge and transition back into the community after hospitalization.

Reviews covered and coordinated services in accordance with established plan benefits, application of evidenced based medical criteria, and regulatory requirements to ensure appropriate authorization of services and execution of the plan’s fiduciary responsibilities.

Identifies and provides recommendations for improvement regarding department processes and procedures.

Maintains current knowledge of organizational or state-wide trends that affect member eligibility and the need for issuance of Determination Notices

Improves clinical and cost-effective outcomes such as reduction of hospital admissions and emergency department visits through on-going member education, care management and collaboration with IDT members.

Provides input and recommendations for design and development of, processes and procedures for effective member case management, efficient department operations, and excellent customer service.

Maintains accurate record of all care management. Maintains written progress notes and verbal communications according to program guidelines.

Participates in approval for out-of-network services when member receives services outside of VNS Health network services.

Provides case direction and assistance ensuring quality and appropriate service delivery.

Keeps current with all health plan changes and updates through on-going training, coaching and educational materials.

For Care Management Only :

Assesses, plans, facilitates and advocates for options and services to effectively manage an individual’s health needs. Promotes quality and cost-effective outcomes at all times.

Provides telephonic case management to members, balancing clinical, social, and environmental concerns.

Qualifications

Licenses and Certifications : Current license to practice as a Registered Professional Nurse or an Occupational Therapist in New York State required Certified Case Manager preferred For SelectHealth ETE Only : Nurse Practitioner (NP) certification with background or degree in Public Health 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

Work 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

Must have experience and qualifications demonstrating knowledge of working with the LTSS eligible population.

Preferred Knowledge of Medicare and Medicaid regulations required

Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills.

Working knowledge of Microsoft Excel, Power-Point, and Word and strong typing skills required

Knowledge of Medicaid and / or Medicare regulations required Knowledge of Milliman criteria (MCG) preferred

For UM Only : Experience must be with a Managed Care Organization or Health Plan.

For SelectHealth ETE Only : Experience in Public Health programming, delivery and evaluation preferred

Experience working with community-based organizations in underserved communities preferred

Pay Range

USD $85,000.00 - USD $106,300.00 / Yr.

About Us

VNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us — we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24 / 7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers 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 the communities and people we serve in New York and beyond.