Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
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Care Manager, UM - Multiple Openings/Remote
🔍 New York, New York
Summary of Position
Support the department’s quality of care and cost containment. Provide utilization management as needed to ensure coordination of health care delivery. Conduct medical appropriateness evaluations of acute care hospital admissions, post-acute care requests, and selected outpatient procedures. Facilitate the achievement of quality clinical outcomes by integrated and collaborative interventions with multiple disciplines, Pre/Post Service. Ensure that members are receiving the appropriate level of care in the appropriate setting for the appropriate length of time within the established guidelines and benefit sets; Pre-service, Concurrent Review, Post-acute and Care Management. Work with interdisciplinary team to utilize the SNP members' Plan of care to achieve improved health outcomes. Provide services per the NYCE contract.
Principal Accountabilities
- Utilize MCG, CMS Guidelines, medical and administrative policies to evaluate medical necessity.
- Identify members at risk and refers for Care management and/or disease management as needed.
- Assess and evaluate member’s needs, coordinate care utilizing approved criteria(s). (Include member and family discussion as necessary).
Maintain utilization time frames are met according to regulatory guidelines (i.e., initial determination decisions, adverse determination notification to providers and members). - Provide appropriate case review; ensure timely notification and correspondence to facilities, members and providers.
- Utilize the member’s contract to determine coverage eligibility. Work with providers and take action in problem solving while exhibiting judgment and a realistic understanding of the issues.
- Prepare and present clinical detail to the Medical Director for final case determination in accordance with regulation and department policy.
- Ensure cost effectiveness and identified opportunities to reduce cost are captured (i.e. reinsurance reporting).
- Refer to Medical Director any questionable quality issues or inappropriate hospitalizations for immediate intervention and/or refer cases that do not meet established criteria for approval of selected procedure or service.
- Regular attendance is an essential function of the job. Perform other duties as assigned or required.
Qualifications
- Associate Degree in Nursing; Bachelor’s preferred
- RN with an active, unrestricted nursing license (Concurrent Review, Medical Management, etc.)
- LPN with an active, unrestricted nursing license (Prior Authorization, Discharge Planning, Retrospective Review)
- MCG Certification prefe4 – 6+ years of clinical experience
- Managed care experience
- Post-acute facility experience
- Care management experience
- Ability to work weekends and holidays on a rotating schedule
- Excellent communications skills (verbal, written, presentation, interpersonal)
- Effectively able to screen and stratify members who are appropriate for care management services
- Ability to: manage a caseload of members in need of care management; and apply the care management process as outlined by the CMSA standards and EH’s policies
- Ability to make appropriate referrals to internal and external programs that meet the member’s needs
- Ability to create and execute care management care plans and document per EH’s policies and procedures
- Ability to speak professionally with all necessary parties associated with the member’s care plan
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.