Registered Nurse (RN) - Utilization Review
VNS Health
Manhattan, NY

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 and 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     
• Interdisciplinary network of colleagues through the VNS Health Social Services Community of Professionals   

What You Will Do

• Conducts clinical assessment including and not limited to, medication reconciliations, post-discharge transitions of care assessment and follow-up post emergency department assessment
• Collaborates with programs to assure compliance with DOH/CMS/NCQA requirements. Coaches, facilitates and monitors continuous improvement to attain strategic quality objectives and industry benchmarks for patient outcomes, satisfaction cost and regulatory requirement.
• Conducts clinical reviews with primary care providers or specialist to address non-adherence and/or clinical diagnosis for HEDIS/QARR exclusion.
• Participates and leads improvement teams and projects and other committees related to performance improvement, measurement and documentation.
• Performs audits on medical records and provide counseling/guidance to PCPs on VNS Health Medical Record Documentation Standards.
• Conducts audits of patient care records. Develops forms, record abstracts, reports, and other tools used to implement concurrent and retrospective patient care review, including the design, testing and evaluation of the review methodology.
• Performs utilization and quality assessment reviews to maintain compliance with Federal and State regulatory requirements. Identifies & analyzes results to inform the development of correction plans.
• Develops action plans in collaboration with management staff based on quality reviews and root cause analysis findings. Makes recommendations to appropriate staff and/or committees about findings of reviews, surveys and studies.
• Participates in the preparation for and assists with site visits of outside provider for the purpose of regulatory quality compliance.
• Investigates patient related complaints, at the direction of the Director. Prepares related reports of investigations and recommendations for correction/improvement.
• Develops training materials for and spreads protocols/standards for patient populations within a collaborative framework.
• Conducts follow-ups and reassessment and reports findings to evaluate whether corrective actions for regulatory issues, compliance, or deficiencies identified in patient complaints/incidents were implemented effectively.
• Develops processes, policies and procedures related to current practice and changes in regulatory and industry requirements. Collects and feeds back data on performance improvement for teams within a region/program.
• Participates in special projects and performs other duties as assigned.

#LI-Hybrid

• License and current registration to practice as a Registered Professional Nurse in New York State required
• License and current registration to practice as a Nurse Practitioner  
• Bachelor's Degree Nursing required
• Master's Degree Nursing preferred
• Enrollment in accredited program within first year and completion of Bachelor’s degree in Nursing by 2015 from a program approved by the New York State Department of Education required 
• Minimum of three years quality improvement experience in a health plan or health care, setting required
• Minimum of one year experience, quality management, practice improvement and compliance preferred
• Demonstrated leadership experience preferred
• Excellent oral, written and interpersonal communication skills, including group facilitation skills required
• Knowledge of basic Performance Improvement tools and methodologies preferred