EmblemHealth

Compensation

Full Description

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