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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Team Lead, Care Manager UM - Multiple Openings/REMOTE
🔍 New York, New York
Summary of Position
Responsible for direct supervision for 5-8+ clinical staff under the guidance of a Supervisor or Lead staff member. Responsible for day to day oversight of workload balancing amongst the team members, staff assignment planning, report oversight. Provide mentoring and coaching to Care Management clinical team to ensure compliance with State, Federal and NCQA requirements related to utilization and care management activities; and ensure 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; Preservice, Concurrent Review, Retrospective, Post-Acute and Care Management. Conduct medical appropriateness evaluations of acute care hospital admissions, post-acute care requests, and selected outpatient procedures to ensure coordination of health care delivery. Facilitate the achievement of quality clinical outcomes by integrated and collaborative interventions with multiple disciplines, Preservice, Concurrent & Post Service. Provide services per the NYCE contract.
Principal Accountabilities
- Direct oversight of team members, including 1:1 meetings and yearly performance evaluations.
- Provide oversight/mentoring of new employees as well as ongoing coaching for performance.
- Obtain guidance from senior leaders related to employee concerns, participate with Manager/Lead in PIP discussions.
- Act as subject matter expert in processes and procedures, use of system, delegated relationships.
- Identify issues with process or casework, escalate and communicate with leadership to initiate problem solving steps.
- Utilize Milliman (MCG) guidelines, CMS Guidelines, medical and administrative policies to evaluate medical necessity.
- Prepare/present clinical detail to the Medical Director for final case determination.
- Assist clinical care manager team to ensure cases are compliance with Emblem Health, State, Federal and NCQA requirements related to utilization and care management activities.
- Refer to Quality team with any questionable quality issues. Resolve escalated issues.
- Ensure utilization time frames are met according to regulatory guidelines (i.e., initial determination decisions, adverse determination notification to providers and members).
- Provide case review and ensure timely notification/correspondence to facilities, members and providers.
- Represent Supervisor and/or Team in projects meetings, requirements sessions, testing, etc.
- Participate in department educational needs, UAT testing efforts, optimization/standardization efforts, documentation.
- Perform other duties as assigned or required; may designate weekend coverage with and for Supervisors.
Qualifications
- RN, LP4 – 6+ years of Nursing experience in an area of focus, including acute care, home care, prior auth, UM experience etc
- Equivalent external experience may be considered in lieu of the 1-year enterprise experience requirement
- Position requires coverage on weekends and holidays as needed
- Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience
- Strong problem-solving skills and ideation, attention to detail and ability to troubleshoot issues raised
- Proficient with MS Office (Word, Excel, PowerPoint, Teams, Outlook)
- SME skill set includes UM system/processes, Enterprise projects/initiatives, areas of focus, IT programs.N with two to four years of college with an active, unrestricted license or certification
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.