EmblemHealth

Supervise and guide non-clinical medical management teams to ensure timely, quality execution of utilization management processes and regulatory compliance. | Bachelor’s degree in nursing, healthcare, business or related field, 4-6+ years relevant experience including 2+ years managed care, supervisory experience, and strong organizational and communication skills. | Summary Of Position • Responsible for the supervision of Medical Management Operations Teams in various non-clinical functions (including Retrospective Review, Post-Service Review, Prior Authorization, Concurrent Review, Discharge Planning, Hospice, Transplant). • Responsible for ensuring the quality and timeliness of all non-clinical functions including accurate administration of benefits, execution of clinical policy, meeting regulatory requirements and timely access to appropriate levels of care. • Provide services per the NYCE contract. Principal Accountabilities • Supervise and guide Team Leads, UM (Non-Clinical), Senior Care Specialists and Care Specialists in the execution of efficient departmental processes designed to manage outpatient and inpatient utilization within the benefit plan. • Ensure the timely and appropriate execution of day-to-day inventory and quality management of authorization requests within regulatory guidelines for non-clinical review/determination. • Manage the proper entry, approval, routing and maintenance of documentation in the Medical Management platform. • Lead team in meeting defined timeframes and performance standards, including the communication of authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, and NCQA and business standards • Evaluate volume trends and align staff accordingly to handle case load within regulatory timeliness requirements. • Perform ongoing analysis regarding volume, case type, longevity and acuities. • Track and report statistics on care management and/or utilization management activities, process measures (e.g. timeliness), quality results, and other measures that affect department objectives. • Foster development and maintenance of relationships with the Clinical review teams, Intake, G&A, Pharmacy, Claims, Networks and other internal partners. • Create and maintain relationships with key provider partners to enable efficient submission and review processes. • Interview, hire, manage performance to support a high-performance team. • Train, coach and mentor staff to ensure understanding of utilization management concepts and effectively apply the concepts to managing members’ health care needs. • Develop, monitor, and communicate performance expectations. • Conduct performance reviews within specified timeframes. • Provide feedback on a regular basis. • Organize after-hour and weekend coverage, as required. • Maintains an environment of quality improvement through continuous evaluation of processes and policies. • Identify and recommend new technologies and process efficiencies. • Other duties as assigned including actively participating on assigned committees and projects. Qualifications Education, Training, Licenses, Certifications • Bachelor’s Degree in nursing, health care, business, or related. Relevant Work Experience, Knowledge, Skills, And Abilities • 4 – 6+ years of relevant, professional work experience. • 2+ years of managed care experience. • Additional years of experience may be considered in lieu of educational requirements. • Supervisory experience. • Ability to organize, prioritize, and effectively manage multiple tasks with competing priority levels and deadlines. • Strong knowledge of care management. • 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). • Strong organizational skills. Additional Information • Requisition ID: 1000002693 • Hiring Range: $68,040-$118,800

Manage daily operations and performance of care management teams, ensure regulatory compliance, provide coaching and training, and oversee clinical documentation and program metrics. | Bachelor’s degree (preferably Nursing), current NY State RN license, CCM certification, 10+ years healthcare experience including 5 years clinical, health plan experience, and strong leadership and problem-solving skills. | Summary Of Position Assist in leading the strategic development of analytics and business intelligence to support population health and market growth initiatives. Collaborate with the AVP, Care management and ACPNY leadership on, and operationalize, CM strategic plan.Works Collaboratively with ACPNY partners to prevent avoidable emergent care visits and re-hospitalizations. Responsible for selection and hiring of qualified staff, ensuring an effective on-boarding and provides ongoing comprehensive training and regular feedback. Responsible for the day to day operation and performance, in collaboration with the APNY team, AVP of Care Management and Field Based Care Managers providing services to EmblemHealth members at the ACPNY location sites. Visit field sites and build relationships with ACPNY colleagues and EH Care Management staff. Provide education, coaching, and mentoring to team members to address performance related issues. Use problem solving abilities to create solutions to operational and clinical issues identified during day to day operations. Serve as an essential link between the Plan’s staff and its internal and external customers to promote and improve communication of initiatives relative to Care Management. Address audit related findings and implement performance improvement strategies. Collaborate with other functional areas within organization to ensure that care managers are implementing EmblemHealth Health Plans policies, procedures and all regulatory mandates, consistent with EmblemHealth plan’s mission, vision, purpose and value statement. Responsible for data collection needed to report on program metrics. Responsible for oversight of HEDIS/STARS and NCQA requirement responsibilities of the Care Management team to support Organizational deliverables. Principal Accountabilities • Manage daily operations of the Care Management team (Managers and Care management team): define metrics; measure performance and productivity against standards; deploy strategies to improve performance. • Train employees in process operations; act as a preceptor to newly hired staff. • Complete quarterly evaluations of staff as needed. • Monitor team caseloads; shift workloads accordingly to meet departmental/organizational needs. • Monitor timeliness and appropriateness of documentation in clinical systems to ensure that accreditation and regulatory standards are met. • Ensure that team members are managing enrollees across the care continuum inclusive of behavioral health so that enrollees have access to needed care and services. • Serve as a clinical resource; attend Care Management rounds. • Monitor employees’ performance regularly and coach employees as needed. Qualifications • Bachelor’s degree, preferably in Nursing • Current unrestricted New York State RN license required • CCM certified required, but consideration will be given for current enrollees/candidates • 10+ years of relevant work experience, preferably with a healthcare provider • 5 years of clinical experience • Health plan experience highly desirable • Familiar with Population Health Management • Experience leading care management teams • Strong problem-solving skills • Detailed oriented and organized • Excellent written and oral communications skills • Strong working knowledge of Microsoft products including Excel and PPT • Strong problem solving and strategy execution abilities. Able to analyze problems and deploy strategies to improve performance in collaboration with the leadership team Additional Information • Requisition ID: 1000002677 • Hiring Range: $113,400-$210,600

Supervise and guide medical management operations teams to ensure quality, timeliness, and regulatory compliance in non-clinical utilization management functions. | Bachelor’s degree, 4-6+ years relevant experience including 2+ years managed care, supervisory experience, strong organizational and communication skills. | Summary Of Position Responsible for the supervision of Medical Management Operations Teams in various non-clinical functions (including Retrospective Review, Post-Service Review, Prior Authorization, Concurrent Review, Discharge Planning, Hospice, Transplant). Responsible for ensuring the quality and timeliness of all non-clinical functions including accurate administration of benefits, execution of clinical policy, meeting regulatory requirements and timely access to appropriate levels of care. Provide services per the NYCE contract. Principal Accountabilities • Supervise and guide Team Leads, UM (Non-Clinical), Senior Care Specialists and Care Specialists in the execution of efficient departmental processes designed to manage outpatient and inpatient utilization within the benefit plan. • Ensure the timely and appropriate execution of day-to-day inventory and quality management of authorization requests within regulatory guidelines for non-clinical review/determination. • Manage the proper entry, approval, routing and maintenance of documentation in the Medical Management platform. • Lead team in meeting defined timeframes and performance standards, including the communication of authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, and NCQA and business standards. • Evaluate volume trends and align staff accordingly to handle case load within regulatory timeliness requirements. • Perform ongoing analysis regarding volume, case type, longevity and acuities. • Track and report statistics on care management and/or utilization management activities, process measures (e.g. timeliness), quality results, and other measures that affect department objectives. • Foster development and maintenance of relationships with the Clinical review teams, Intake, G&A, Pharmacy, Claims, Networks and other internal partners. • Create and maintain relationships with key provider partners to enable efficient submission and review processes. • Interview, hire, manage performance to support a high-performance team. • Train, coach and mentor staff to ensure understanding of utilization management concepts and effectively apply the concepts to managing members’ health care needs. • Develop, monitor, and communicate performance expectations. • Conduct performance reviews within specified timeframes. • Provide feedback on a regular basis. • Organize after-hour and weekend coverage, as required. • Maintains an environment of quality improvement through continuous evaluation of processes and policies. • Identify and recommend new technologies and process efficiencies. • Other duties as assigned including actively participating on assigned committees and projects. Qualifications • Bachelor’s Degree in nursing, health care, business, or related • 4 – 6+ years of relevant, professional work experience • 2+ years of managed care experience • Additional years of experience may be considered in lieu of educational requirements • Supervisory experience • Ability to organize, prioritize, and effectively manage multiple tasks with competing priority levels and deadlines • Strong knowledge of care management • 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) • Strong organizational skills Additional Information • Requisition ID: 1000002693 • Hiring Range: $68,040-$118,800