Clinical Evaluation Manager (RN) • MA Care Management
: Job Details :

Overview

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. This position is mostly remote (minimum of 1x per month in the office).

$85,000.00 - $106,300.00 Annual

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

• Conduct comprehensive reviews of all components related to requests for services, including clinical record reviews and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers, and other relevant sources as necessary.
• Examine standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care, and lengths of stay. Perform prior authorization and concurrent reviews to ensure extended treatment is medically necessary and being conducted in the right setting. Review requests for outpatient and inpatient admission; approve services or consult with medical directors when cases do not meet medical necessity criteria.
• Ensure compliance with state and federal regulatory standards and VNS Health policies and procedures.
• Participate in case conferences with management.
• Identify opportunities for alternative care options and contribute to the development of patient-focused plans of care to facilitate a safe discharge and transition back into the community after hospitalization.
• Review covered and coordinated services in accordance with established plan benefits, application of evidence-based medical criteria, and regulatory requirements to ensure appropriate authorization of services and execution of the plan's fiduciary responsibilities.
• Identify and provide recommendations for improvement regarding department processes and procedures.
• Maintain current knowledge of organizational or state-wide trends that affect member eligibility and the need for issuance of Determination Notices.
• Improve clinical and cost-effective outcomes such as reduction of hospital admissions and emergency department visits through ongoing member education, care management, and collaboration with IDT members.
• Provide input and recommendations for design and development of processes and procedures for effective member case management, efficient department operations, and excellent customer service.
• Maintain accurate records of all care management. Maintain written progress notes and verbal communications according to program guidelines.
• Participate in approval for out-of-network services when members receive services outside of VNS Health network services.
• Provide case direction and assistance ensuring quality and appropriate service delivery.
• Keep current with all health plan changes and updates through ongoing training, coaching, and educational materials.
• Assess, plan, facilitate, and advocate for options and services to effectively manage an individual's health needs. Promote quality and cost-effective outcomes at all times.
• Provide telephonic case management to members, balancing clinical, social, and environmental concerns.
• Provide analysis of initial health evaluations and comprehensive assessments of the member/family psychosocial status and case management needs. Participate in the development, coordination, and implementation of the care plan to address specific needs of the member/family, including thorough transitions between settings of care.
• Coordinate with community providers to ensure efficient and effective transitions and delivery of care in the home and community.
• Consult with the member, family, and members of the inter-disciplinary team to coordinate the treatment plan, education, self-care techniques, and prevention strategies.
• Verify that all aspects of the clinical record are in agreement with the member's clinical and functional status. Utilize VNS Health and state-approved assessment and documentation as well as interviews with members, family, and care providers in decision-making.
• Perform annual clinical co-visits for nurses as well as two initial co-visits during the first six months for new hires as follows: one within the first three weeks and a second within the first six months. Provide feedback to therapists and management; assist in the development of plans to address improvement needs as appropriate.

Licenses and Certifications:Current license to practice as a Registered Professional Nurse.Education:Associate's Degree in Nursing or a Master's degree required. Bachelor's Degree or Master's degree in nursing preferred.Work Experience:Minimum two years of experience with a 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 preferred. Knowledge of Medicare and Medicaid regulations required. Excellent organizational and time management skills, interpersonal skills, and verbal and written communication skills required. Working knowledge of Microsoft Excel, PowerPoint, and Word, and strong typing skills required. Knowledge of Medicaid and/or Medicare regulations required. Knowledge of Milliman criteria (MCG) preferred.