Clinical Evaluation Manager - Utilization Management

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 :

Qualifications

Licenses and Certifications : Current license to practice as a Registered Professional Nurse in New York State required

Certified Case Manager preferred

Education : Associate's Degree in Nursing or a Master's degree

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. 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.

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

VNS Health is one of the nation's largest nonprofit home and community-based health care organizations. We are an equal opportunity employer and welcome applicants of diverse backgrounds.

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