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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Nurse Manager, Utilization Management (Remote)
Summary of Position
Manage the utilization review process, ensuring that healthcare services are medically necessary, appropriate, and costeffective. Oversee the day-to-day operation and performance of specific functional areas within the compliance with health plans policies, procedures and all regulatory mandates. Manage the supervision of clinical Utilization Management (UM) staff.
Principal Accountabilities
- Manage the day-to-day activities of the clinical UM teams by providing guidance and leadership.
- Oversee accuracy and production of cases with regulatory and accreditation mandates.
- Ensure the delegation of cases across staff to meet set timeframes.
- Identify areas of clinical issues that need corrective action and implement changes needed.
- Manage, train, and oversee daily supervision of clinical staff.
- Create a collaborative, flexible environment within the department.
- Oversee the supervision of staff to complete JMAC specific processes accurately and efficiently within specific contract requirements.
- Track and evaluate data related to utilization patterns, identifying trends, and developing strategies to address areas for improvement.
- Represent Concurrent Review and JMAC function in meetings with internal leaders, other departments and senior leadership.
- Work with medical staff, case managers, and other healthcare professionals to coordinate care and resolve any utilization-related issues.
- Enforce and adhere to all company and department policies and procedures in confidentiality, regulatory or contractual mandates and HR policy.
- Serve as lead for clinical rounds in coordination with a Medical Director.
- Represent the department head at meetings as necessary.
Qualifications
- Bachelor’s Degree
- Registered nurse with an active, unrestricted license or certification
- 5 – 8+ years relevant, professional clinical work experience
- 5+ years management experience in health care setting, preferably in managed care
- Additional experience/specialized training may be considered in lieu of education
- Staff/process management experience
- Knowledge of Utilization Management, HMO operations, and work processes
- Knowledge of New York State and Federal regulatory requirements
- Knowledge of clinical medical practice, hospital and ALC procedures, government regulations, Utilization Management criteria sufficient to make judgments and offer guidance about appropriateness of medical care
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.)
- Strong communication skills (verbal, written, interpersonal) with all types/levels of audiences
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.