EmblemHealth

Care Manager, Concurrent Review (Remote)

EmblemHealth • $75K — $95K *
New York, NY 10025In-Person
Healthcare
Less than 5 years of experience
1 week ago
Job Overview by Ladders

Qualifications

  • Associate's or Bachelor's degree in nursing.
  • Valid RN License without restriction.
  • CME accreditation in specific specialties may be required.
  • Certification in utilization or care management preferred.
  • 4-6+ years of Nursing experience.
  • Experience in case and/or utilization management and managed care.
  • Strong communication and organizational skills.

Responsibilities

  • Perform clinical reviews in the Medical Management Operations.
  • Ensure accurate benefit administration and timely access to care.
  • Act as clinical coordinator, collaborating with members and facilities.
  • Maintain documentation in the TPH platform meeting performance standards.
  • Communicate authorization decisions and benefit information to providers and members.
  • Review member and provider requests for benefits and claims.
  • Research guidelines and networks for coverage determinations.

Benefits

  • Collaborative work environment involving interdisciplinary teams.
  • Opportunity to engage in clinical case presentations.
  • Access to tools for professional development and training.
  • Participation in quality and efficiency improvement initiatives.
Full Job Description
Summary of Position
  • Perform clinical reviews within the Medical Management Operations Concurrent Review utilization management department.
  • Ensure accurate administration of benefits, execution of clinical policy and timely access to appropriate levels of care.


Principal Accountabilities
  • Under the direction of the leader, is responsible for the execution of efficient departmental processes designed to manage inpatient utilization within the benefit plan.
  • Act as the clinical coordinator collaborating with members and facilities to evaluate member needs within the inpatient setting.
  • Establish and maintain active working relationships with assigned facility care managers/utilization management departments to facilitate appropriate clinical reviews and patient care.
  • Enter and maintain documentation in the TPH platform meeting defined timeframes and performance standards.
  • Communicate authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, and NCQA and business standards.
  • Review and investigate member and provider requests to determine appropriate utilization of benefits and/or claim adjudication.
  • Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making coverage determinations and recommendations.
  • Prepare and present clinical case summaries in routine inpatient rounds.
  • Maintain an understanding of utilization management, program objectives and design, implementation, management, monitoring, and reporting.
  • Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager.
  • Actively participate on assigned committees.
  • Perform other related projects and duties as assigned.


Qualifications

Education, Training, Licenses, Certifications
  • Associate's degree or bachelor's degree in nursing.
  • Valid RN License without restriction.
  • May require a CME accreditation in specific specialties.
  • Certification in utilization or care management preferred


Relevant Work Experience, Knowledge, Skills, and Abilities
  • 4 - 6+ years of Nursing experience.
  • Case and/or utilization management/care coordination and managed care experience.
  • Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience.
  • Organizing and prioritizing skills, and strong attention to detail.
  • Trained in the use of Motivational Interviewing techniques.
  • Experience working in physician practice and/or with electronic medical records.
  • Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.).
  • Proficiency with the use of mobile technology (Smartphone, wireless laptop, etc.).

About EmblemHealth

EmblemHealth is a non-profit health insurance company based in New York City. It is one of the largest non-profit health insurers in the United States, serving over 3 million people. EmblemHealth offers a range of health insurance plans, including HMO, PPO, and EPO plans, as well as Medicare and Medicaid plans. The company also offers wellness programs and disease management services. EmblemHealth was formed in 2006 through the merger of Group Health Incorporated (GHI) and the Health Insurance Plan of Greater New York (HIP). The company has offices in New York City and Albany, New York.
Learn more about EmblemHealth
Size
3,000 employees
Industry
Healthcare
Net Income
-$100 million
Founded
2006
5 Year Trend
-5%
Revenue
$10 billion
NASDAQ
* Ladders Estimates

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