Quality Review Manager
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.
Compensation:
$93,400.00 - $116,800.00 Annual
• 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.Qualifications
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 from a program approved by the New York State Department of Education required or in Nursing required 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
About Us
VNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 125 years, our commitment to health and well-being is what drives us—we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.
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Mission & Values
As a team member of VNS Health, you share a passion for improving the health of patients through best-in-class care in the home and the community.
Inclusive Culture
At VNS Health, our priority is to create an environment where every team member feels they belong and are included.
Total Rewards
We provide our team members a well-rounded employment experience, competitive compensation, and a robust and affordable benefits package that serves you and your family. Our Total Rewards Program at VNS Health is an investment in your health, wealth and life.