Clinical Evaluation Manager, Utilization Management

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.

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.

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 Utilization Management Only: Issues Determinations, Notices of Action, and other forms of communication to members and providers which communicate VNS Health’s determinations. Ensures all records/logs related to decision requests, Notices of Action, and other communications required by state or federal regulations are saved in the Utilization Management System. Reviews, evaluates and determines the appropriateness of requests, utilize the most appropriate clinical care guidelines based on clinical practice guidelines. Adheres to all federal and regulatory requirements. Evaluates and analyzes care and utilization trends/issues and identifies opportunities for better coordination of members’ care. Weekend Rotation.