Clinical Evaluation Manager-mostly remote
: Job Details :

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.

$85,000.00 - $106,300.00 Annual

• 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 Care Management Only: Assesses, plans, facilitates and advocates for options and services to effectively manage an individual's health needs. Promotes quality and cost-effective outcomes at all times.

• Provides telephonic case management to members, balancing clinical, social, and environmental concerns.

• Provides analysis of initial health evaluation and comprehensive assessment of the member/family psychosocial status and case management needs.

• Participates 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.

• Coordinates with community providers to ensure efficient and effective transitions and delivery of care in the home and community.

• Consults with the member, family, and members of the inter-disciplinary team to coordinate the treatment plan, education, self-care techniques and prevention strategies.

• Verifies that all aspects of the clinical record are in agreement with the member's clinical and functional status. Utilizes VNS Health and state approved assessment and documentation as well as interviews with members, family, and care providers in decision-making.

• Performs 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 first three weeks and a second within the first six months. Provides feedback to therapist and management; assists in development of plans to address improvement needs as appropriate.

• 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.

• For SelectHealth End the Epidemic (ETE) Only: Provides clinical and programmatic support to the ETE grant project. Coordinates and participates in ETE conference calls with designated AIDS Centers (DAC) sites. Participates in weekly outreach team case conferences. Coordinates sharing of information between subcontractor Community Based Organizations (CBOs), DAC, and internal staff at VNS Health.

• For Palliative Care Only: Understands and supports ability to cope with patients' illness. Provides emotional, spiritual, and practical support for patient and family. Reviews tools, programs and other resources for potential serious illness program appropriate patients and make referral as necessary. Provides education to patients and their families to better understand patients' disease and diagnosis. Facilitates open discussion about treatment choices for patient's illness (including difficult and complex choices) and management of symptoms. Provides expertise in treatment of pain and other symptoms. Assists the patient in making a smooth transition from the hospital to home care/nursing home setting. Assists patients and families in medical decision making and in coordinating care.

• Participates in special projects and performs other duties as assigned.

Current license to practice as a Registered Professional Nurse or an Occupational Therapist in New York State required. Certified Case Manager preferred. For SelectHealth ETE Only: Nurse Practitioner (NP) certification with background or degree in Public Health preferred.

Associate's Degree in Nursing or a Master's degree in Occupational Therapy required. Bachelor's Degree or Master's degree in nursing preferred.

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. For SelectHealth ETE Only: Experience in Public Health programming, delivery and evaluation preferred. Experience working with community-based organizations in underserved communities preferred.