Conducts daily reviews of case files, letters, and database records against required criteria. Ensures compliance with VNS Home care policies and procedures, regulatory requirements and business practices up to an including contractual arrangements with payers. Prepares summary reports and provides recommendations to reduce errors and improve process performance. Works under general supervision.

$93,400.00 - $116,800.00 Annual

What We Provide

• Attractive sign-on bonus and referral bonus opportunities
• Generous paid time off (PTO), starting at30 days of paid time offand 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

What You Will Do

• Develops and maintains current knowledge of state and federal regulatory and contractual requirements related to all aspects of grievances and appeals for Medicare and Medicaid managed care organizations. Serves as subject matter resource to team members, supervisors and management staff.
• Conducts daily detailed quality reviews of Population Health caseloads, including database records, shared drive file folders, resolution documentation, and letter review. Provides feedback to staff on audit results; analyzes and identifies trends; and provides recommendations to management regarding opportunities to reduce errors and improve processes and performance.
• Identifies and assists with challenging cases and cases with greater potential impact on department compliance, STARS, and other payer priorities.
• Provides coaching to staff if an urgent issue is identified. Trouble-shoots recurring problems; escalates issues to department management, as appropriate.
• Works with VNS Home Care Education to ensure that all -audit and quality review related training documents are updated with the most up-to-date information. Conducts training for new hires and existing staff.
• Analyzes and communicates root cause of audit findings. Documents and implements remediation plans for errors/issues identified through root cause analysis or via other avenues.
• Produces performance-focused reports which include results trending, analysis summaries, conclusions and recommendations. Supports management in creation of intra-and inter-departmental reporting of audit and quality review data, as needed.
• Assists with preparation of files and external facing documents for regulatory and customer audits. Assists with audits conducted by internal or external reviewers. Assists with execution of corrective action plans.
• Participates in special projects and performs other duties as assigned.

Licenses and Certifications:

• Current license and registration to practice as a Registered Professional Nurse in New York State required or
• New York State License and current registration in Physical Therapy required

Education:

• Bachelor's Degree in Physical Therapy or Nursing from a program approved by the New York State Department of Education required or
• Master's Degree in Nursing preferred

Work Experience:

• Minimum four years professional experience in health care, including a minimum of two years in Quality required
• Excellent verbal/written communication skills required

Proficient computer and typing skills, and knowledge of Microsoft Office (Word and Excel) and database software required
Experience in one or more of the following areas: Audits, Compliance, and Medicare/Medicaid reporting required
Excellent verbal and written, presentation, communication, and writing skills required
Demonstrated ability to work effectively with employees at all levels of the organization required