OverviewManages the utilization management team to ensure that standards for service delivery and team/staff performance levels are met or exceeded. This includes supporting the VNS Health Plans teams on a day-to-day basis for utilization issues, problem resolution, complaint resolution, and other service-related issues. Manages and coordinates the activities of the VNS Health Plans teams by ensuring that appropriate and high-quality services are provided and are consistent with VNS Health mission, principles, policies, and regulatory compliance. Works under general supervision.
Compensation:$98,200.00 - $130,800.00 Annual
• Reviews specific utilization issues or requests with Clinical Review team, focusing on problem-solving, response to actual or potential quality issues or complaints, and/or approvals requiring next level authorization (e.g., utilization management, high cost services, out of network services, etc.).
• Investigates, analyzes, and reports to VNS Health Plans leadership on trends related to service requests and decisions, including recommendations regarding interventions and outcomes.
• Monitors and ensures that utilization management processes are followed by the service operations staff, utilization staff, and the interdisciplinary care team to ensure cost-effective quality outcomes.
• Assures compliance with regulatory requirements and achievement of audit targets. Collaborates with Compliance department to ensure that all necessary corrective actions are enforced strictly and timely.
• Participates in development and implementation of the Quality Assurance and Compliance initiatives; collaborates across team, regions, and programs with VNS Health Plans management team.
• Works with VNS Health Plans leadership to implement high quality and cost-effective member services provided by assigned staff or through contract relationships in both home and community-based settings.
• Manages and evaluates staff in delivery and coordination of utilization management review services in compliance with CMS guidelines and consistent with evidence based guidelines, state and federal regulations and VNS Health policies and procedures. Assures quality of services, appropriate access and utilization, within the VNS Health Plans contracts.
• Acts as resource for staff on complex cases and facility discharge planning to develop and ensure safe and appropriate service planning. Monitors and analyzes facility discharge reports to determine trends and mitigate any discerned risks.
• Facilitates and schedules Clinical Rounds to establish best practice and promote creative critical thinking.
• Works collaboratively with the Education department and key staff regarding specific learning needs/performance issues related to the team or individual members and uses feedback to develop/implement strategies (e.g., promotion of key partnerships) to improve quality of the plan’s programs.
• Responsible for financial management of the team. Demonstrates ability to manage to the Medical Loss Ratio. Strives to ensure appropriate service utilization, staff productivity, and coverage.
• Generates management reports via the care/utilization management systems and demonstrates competency as a super user of these systems.
• Performs all duties inherent in a managerial role. Ensures effective staff training, evaluates staff performance, provides input for the development of the department budget, hires, promotes and terminates staff, and recommends salary actions, as appropriate.
• Participates in special projects and performs other duties as assigned.
QualificationsLicenses and Certifications:License and current registration to practice as a registered professional nurse in New York State Required. Valid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needs.
Education:Bachelor's Degree or equivalent work experience in management for a health plan or utilization/case management Required. Master's Degree in Nursing or Health Care Administration Preferred. Case Management Certification Preferred.
Work Experience:Minimum of four years experience in home care, care management or related field, including three years of progressive experience in case or utilization Management Required. Effective oral/written communication and interpersonal skills Preferred.
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