Job Specification Details

Specialized nursing work at a professional level assessing, evaluating, documenting, and/or authorizing clinical service delivery. Areas may include: inpatient and outpatient services, Skilled Nursing Minimum Data Set (MDS), clinical procedures, durable medical equipment, high tech nursing services, in home care and/or holistic clinical case management, to support health and health outcomes and payment for services for individuals with a variety of complex health conditions. Setting is based upon agency of hire and may include office, facility, or field based work. Individual reports to nurse supervisor, manager and/or director and works closely with the Medical Director.

Work may include assessment for clinical eligibility, clinical/technical ongoing review, service authorization, concurrent reviews, and/or holistic case management for population of responsibility.

The nurse works with a multidisciplinary team of professionals to determine needs, service appropriateness, assures criteria based clinical review/necessity, and recommends service authorization and/or supports medical adherence, based on evidence based standards, as well as insurance rules and coverage levels (may include Medicaid, Medicare, Veterans Benefits, and private or public insurance plans).

The incumbent may be expected to: review clinical criteria; recommend and/or develop policies and procedures to support internal operations, and Medicaid rules; and to enhance and assure delivery of quality services for individuals; while simultaneously facilitating cost effective service utilization.

The incumbent may oversee development and implementation of a plan of care in partnership with the medical home or facility to support clinical and behavioral change and effective self-management.

Performs overall clinical health assessment, person-centered planning, and coordination as well as service recommendation and/or authorization as appropriate while assuring appropriate utilization of services.

Utilizes approved person-centered planning process, assessment or screening tools, standards of care, evidence based practice, and policies and procedures to perform required work.

May communicate with the primary care provider, specialty service providers, the individual and/or partners as appropriate to facilitate and assure the approved services/treatment/case management plan is implemented on behalf of the individual and according to policies and regulations.

Continued monitoring and evaluation of the authorized/indicated health service plan and necessary case management to support health improvement and assure service quality and/or overall adherence to evidence based care guidelines.

Applies a person-centered planning process, appropriate rules, regulations, policies and procedures in the coordination of recommended health care services and/or related health education/training, as appropriate.

Participates and provides ongoing education and training to providers.

Identifies changes in overall health care patterns/trends and recommends adaptation of policies and procedures as appropriate, to enhance clinical results and to prevent inappropriate utilization.

May also be required to perform various quality assurance, quality improvement, and Program Integrity responsibilities based on agency specific requirements, division or unit priorities and strategic plan, goals, and objectives.

May be required to prepare related reports to support division or unit requirements and monitor progress in achieving strategic goals and objectives.

Performs other related duties as required.

Duties are performed in a facility, standard office setting and/or in the community. Extensive travel may be required, for which private means of transport must be available. Certain functions may require duty outside of normal work hours. Some resistance or objection to standards may be anticipated, requiring tact and diplomacy to achieve proper action. Duties involve need for effective communication and working relationships with a diverse group of stakeholders, including the individual, family members and a number of health care disciplines and service providers; and operational integration with various other health care reform initiatives. Critical assessment skills are necessary to promote personal and client safety.

Considerable knowledge of and competency applying the principles and practices of professional nursing and case management.

Considerable clinical nursing knowledge related to multiple disease processes of adults and children and/or adults and children with emotional, physical and/or developmental disabilities

Considerable knowledge and understanding of case management and care coordination; disease management; evidence based clinical practice; standards of care; and utilization management.

Considerable knowledge of medical procedures, equipment, and evidence based care.

Considerable knowledge of clinical practice guidelines and evidence based standards for diverse set of medical conditions.

Considerable knowledge of standards of practice related to health care delivery including Nurse Practice Act, HIPAA, mandatory reporting, etc.

Considerable computer aptitude, skills and knowledge with an ability to work in multiple data systems to organize and manage work efficiently and effectively.

Knowledge of the organization and service delivery systems of health care providers.

Knowledge of human service resources for comprehensive care delivery and sustainability.

Awareness of impacts of health care reform on insurances and primary care practice priorities and operations.

Ability to understand, interpret and apply state and federal regulations and directives pertaining to health care.

Ability to make accurate and professional patient care decisions and utilization management appropriateness based on available guidelines and established criteria.

Ability to communicate professionally and effectively orally and in writing with diverse audiences, including facilitating provider and team meetings.

Considerable computer aptitude, skills and knowledge, with an ability to work in multiple data systems to organize and manage work efficiently and effectively.

Ability to establish and maintain effective working relationships within the departments within the Agency of Human Services, providers, beneficiaries, their representative organizations, and their advocates and representatives, other agencies/departments/offices in state government involved in the management of health insurance activities.

Possession of (or eligible for) licensure as a Registered Nurse (RN) in Vermont OR eligible to practice in the state of Vermont via a multi-state license AND three (3) years or more of professional nursing experience in an acute hospital setting, long term care, health insurance carrier, or within a community health/public health setting.

NOTE: Must maintain Vermont or multi-state licensure as a Registered Nurse as a condition of employment.

Bachelor of Science in Nursing (BSN).

Reliable means of personal transportation is required for work out of the office or in the community and field based settings.

Candidates must pass any level of background investigation applicable to the position. In accordance with applicable hiring standards, fingerprint supported criminal record checks, adult and child abuse registry checks, the Office of Inspector General exclusion database, and motor vehicle driving record checks, as appropriate to the positon under recruitment, will be conducted on candidates, with the exception of those who are current classified state employees seeking transfer, promotion, or demotion into a classified position or are persons exercising re-employment (RIF) rights.

For positions at the Vermont Veterans' Home: Any person who has had a charge of abuse, neglect or exploitation substantiated against him or her is not eligible under the Vermont Veterans’ Home licensing requirements. Candidates must pass any level of background investigation applicable to the position, including Vermont and national criminal record checks, adult and child abuse registry checks, the Office of Inspector General exclusion database, and motor vehicle driving record checks where applicable.