Overview
Oversees and manages the utilization management and medical management functions within VNS Health. Possesses a deep understanding of healthcare operations, utilization management principles, and regulatory requirements. Works closely with cross-functional teams, including medical directors, nurses, care managers, and administrative staff, to ensure efficient and effective utilization of healthcare resources. assessment nursing staff, vendor performance, and assessment quality audits; owns and manages UAS-NY database, and monitors and tracks assessment scores. Ensures the health plan meets the Center for Medicare Services (CMS), State and other external regulations for all medical management and member services areas. Works under general supervision.
- Designs and implement utilization management programs, policies, and procedures to ensure appropriate utilization of healthcare services while maintaining high-quality patient care outcomes.
- Oversees the utilization review process to evaluate the medical necessity, appropriateness, and efficiency of healthcare services rendered. This includes reviewing medical records, claims data, and other relevant information to make utilization decisions.
- Oversees Clinical Assessment unit and external delegated vendor partners to ensure timely assessments of each member's medical, behavioral health, long-term services and supports, and social needs. Ensures the assessments are provided within the standards of nursing practice and in accordance with established guidelines and DOH/CMS regulations.
- Oversees Medical Management functions for utilization management (UM) for Inpatient, Outpatient, and rehab/skilled services for members in VNS Health Plans products.
- Provides leadership, guidance, and supervision to the utilization management team, including nurses, case managers, and administrative staff. Set performance goals, conduct regular performance evaluations, and provide coaching and mentoring to ensure team members meet objectives and deliver high-quality work.
- Ensures compliance with all applicable regulatory requirements, including those set by government agencies, accreditation bodies, and health plans. Monitor changes in regulations and update policies and procedures accordingly.
- Collaborates with the quality management department to identify areas for improvement in the utilization management process. Implement quality improvement initiatives, monitor performance metrics, and drive continuous improvement efforts.
- Fosters effective working relationships with various departments, including medical staff, claims, provider network management, and finance. Collaborate with these departments to streamline processes, resolve issues, and optimize resource utilization.
- Develops key performance indicators (KPIs) and metrics to monitor the effectiveness of utilization management activities. Generate reports and presentations to communicate performance trends, areas of concern, and improvement opportunities to senior leadership.
- Stays up-to-date with changes in healthcare policies, reimbursement models, and industry best practices related to utilization management. Applies knowledge to inform decision-making and enhance operational efficiency.
- Collaborates with Medical Director to coordinate appropriate utilization to meet member needs. Co-chairs UM/CM committee and attends QIC committee meetings.
- Oversees the development and implementation of long-range strategic plans, goals and objectives. Ensures that strategic plans, goals and financial targets are implemented within the business units to support the growth and profitability of the plan.
- Manages the effectiveness of clinical operations utilizing MCG, LCD, NCD and medical policies/utilization policies to ensure appropriate and timely determinations for UM staff. Oversees quality of care using benchmark and objective data, including but not limited to, member health outcomes, satisfaction survey results (CAHPS), utilization metrics, and HEDIS star ratings.
- Participates in special projects and performs other duties as assigned.
Qualifications
Licenses and Certifications:
License and current registration to practice as a Registered Professional Nurse in New York State preferred
Education:
Bachelor's Degree in healthcare administration, nursing, or a related field required
Master's Degree in healthcare administration, nursing, or a related field preferred
Work Experience:
Minimum of eight years of experience in utilization management, with at least 3 years in a leadership or managerial role required
In-depth knowledge of healthcare operations, utilization management principles, and regulatory requirements required
Strong understanding of healthcare reimbursement models, including fee-for-service and value-based care required
Excellent analytical and problem-solving skills, with the ability to make sound utilization decisions based on clinical guidelines and evidence-based medicine required
Proven track record in driving process improvement initiatives and achieving measurable results required
Strong leadership abilities, including the ability to inspire and motivate a diverse team required
Exceptional communication and interpersonal skills, with the ability to collaborate effectively with internal and external stakeholders required
Pay Range
USD $193,600.00 - USD $258,200.00 /Yr.
About Us
VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We're one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.