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 Specialist UM - REMOTE
🔍 New York, New York
Summary of Position
Support the non-clinical functions required for successful Utilization Management. Ensure all work assigned to or by this position is completed in appropriate timeframes and in keeping with all organizational, regulatory and legal requirement. Responsible for direct supervision for 5 – 8+ non-clinical staff. Responsible for day-to-day oversight of workload balance among team members, staff assignment planning, and reporting oversight. Represent the team and/or Supervisor in projects/initiatives by participating in requirements, design and development and testing sessions or other meetings as appropriate. Responsible for a caseload 50% of the time. Povide services per the NYCE contract.
Principal Accountabilities
- Direct oversight of Care Specialists and Sr. Care Specialists, including 1:1 meetings and yearly performance evaluations.
- Provide oversight/mentoring of new employees with ongoing performance coaching.
- In conjunction with the Supervisor, participate in the PIP process for assigned staff. Also participate in the hiring process with the Supervisor.
- Provide direction to the team on daily work, schedules, issues, questions, etc.
- Resolve escalated or executive issues.
- Serve as subject matter expert in processes and procedures, use of system, delegated relationships that demonstrate a higher level of clinical functioning in role.
- Identify issues, escalate, and communicate with leadership to initiate problem solving.
- Ensure organizational, legal and regulatory requirements are met for work assigned to or by this position.
- Provide case review (when necessary) and assure timely notification and correspondence to facilities, members, and providers.
- Maintain a daily caseload in accordance to the productivity needs of the Total Population Health team.
- Conduct preauthorization review activities in support of clinical staff responsible for determinations, including management of benefit exclusion determinations, in accordance with departmental policies.
- Communicate authorization decisions and important benefit information to providers and members in accordance with applicable standards.
- Interact with various departments throughout the Enterprise and contribute to the resolution of interdepartmental issues.
- Lead and develop team to quickly assess and diagnose root causes.
- Research and resolve claim/referral and authorization discrepancies/issues to facilitate timely and accurate claims adjudication in compliance with company policy and regulatory requirements.
- Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager.
- Work collaboratively with delegates to promote and maintain all established processes, policies and relationships.
- Work collaboratively with senior leadership as a critical component of the multi-disciplinary team to facilitate all nonclinical processes and activities.
- Train and develop assigned staff under the direction of the Manager/Lead.
- Perform other related projects and duties as assigned or required.
Qualifications
- Bachelor’s degree
- 3 - 5+ years’ experience in managed care, preferably in UM ops for multiple lines of business/authorization processes
- Experience in non-clinical prior authorization/care management and/or utilization management
- 1-year internal (company) experience
- Additional experience/specialized training may be considered in lieu of educational requirements
- Equivalent external experience may be considered in lieu of the one-year enterprise experience
- Experience associated with discharge planning, care transition interventions, standard quality measures and/or prior authorization
- Strong knowledge of medical terminology, ICD and CPT coding
- Knowledge of community health, social service agencies and other community
- Strong oral and written communication, organizational, analytical and interpersonal skills
- Ability to establish priorities, work independently and proceed with objectives without direct supervision
- Must manage a flexible work schedule to meet member and/or caregiver and departmental scheduling needs
- User experience in a highly automated environment with strong personal computer literacy on Windows
- Bilingual in English/Spanish
- Expertise in customer service, data entry, non-clinical review, routing, etc. and competency in multiple areas of focus, such as acute care, home care, prior authorization, UM experience etc
- Requires coverage on weekends and holidays as needed
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.