Clinical Care Manager

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 and 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.

Licenses and Certifications:

• Current license to practice as a Registered Professional Nurse
• Certified Case Manager preferred

Education:

• Associate's Degree in Nursing
• 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
• 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