Clinical Evaluation Manager, UM MLTC
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POST DATE 9/13/2016
END DATE 12/1/2016
Visiting Nurse Service Of New York
Visiting Nurse Service of New York (VNSNY) is the nation s largest not-for-profit community-based health system. VNSNY provides a comprehensive array of home- and community-based programs, including health plans, tailored to the needs of high-risk, vulnerable New Yorkers, improving their quality of life. Each day, more than 18,000 VNSNY employees including nurses, rehabilitation therapists, social workers, dieticians, other allied professionals, and paraprofessionals deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to more than 35,000 patients, helping them to live the best lives possible.
RESPONSIBILITIES AND QUALIFICATIONS:
* Assesses member needs and identifies solutions that promote high quality and cost effective health care services.
* Manages requests for services from providers, members, and care management team and renders clinical determinations in accordance with VNSNY CHOICE policies as well as applicable state and federal regulations.
* Delivers timely notification detailing VNSNY CHOICE clinical decisions.
* Coordinates with VNSNY CHOICE team, subject matter experts, physicians, member representatives, and discharge planners to ensure care is appropriate, timely and cost effective. Utilizes VNSNY and state approved assessment questionnaire, guidelines and documentation as well as interviews with members, family, and care providers in decision-making.
* Performs in-home assessment for members who have identified significant changes in condition since last in-home assessment; provides comprehensive review and determination of member s needs, including completion of UAS assessment questionnaire, tasking tool, and a projected service plan.
* Visits include all areas serviced by VNSNY CHOICE including upstate and downstate counties.
Licensure: Current license to practice as a Registered Professional Nurse in New York State required. Certified Case Manager preferred.
Education: Bachelor's degree or Master's degree in nursing preferred.
Experience: Minimum two years of utilization review or care management experience at a Managed Care Organization or Health Plan required. Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills required. Demonstrated strong relationship management skills, including a high degree of psychological sophistication and non-aggressive assertiveness required. Demonstrated successful conflict management skills and negotiation of &rsquot;win-win&rsquot; solutions required. Working knowledge of Microsoft Excel, Power-Point, and Word required. Knowledge of Medicaid and/or Medicare regulations required. Knowledge of Milliman criteria (MCG) preferred.
VNSNY is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to race, color, religion, sex, national origin, disability or protected veteran status. If you would like more information about your EEO rights, then please visit: