Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Program Specialist

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Manager & Professional
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190AI Requisition #
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Provides telephonic and in-person health navigation services to high-risk members while located in community settings such as ACPNY offices, Neighborhood Care Centers, EH Pharmacies and Hospitals. Navigator services include Care Transition and Complex Care Interventions, telephonic outreach, dissemination of educational messages, and linkage to internal and external resources. In addition, health navigators facilitate compliance with HEDIS measures and enhance HCC coding. Health navigators work directly with members, caregivers and other appropriate collaterals and communicate regularly with Care Management team, physicians and nursing care teams to enhance the coordination of care for members.

Responsibilities:
  • Supports Care Management Interventions set forth by licensed care team including discharge plan review, medication review/reconciliation, plan of care and ensures PCP or specialist appointment, and links member to internal and external resources.
  • Identifies all HEDIS measures for which the member is eligible, determines if member is already compliant and if works with the member to achieve HEDIS compliance for all eligible measures.
  • Meets productivity standards related to total caseload and enrollment of members while providing outreach to identified high risk members including Transition of Care, Emergency Department high utilizers and Complex Care Program.
  • Actively collaborates with the care team that includes physicians, nursing staff, Community partners and EmblemHealth care management team.
  • Identifies all HEDIS measures for which the member is eligible, determines if member is already compliant and if works with the member to achieve HEDIS compliance for all eligible measures.
  • For Medicare members, identifies chronic conditions that have not been diagnosed and documented in the calendar year and works with PCP to ensure member has a PCP visit and the conditions are appropriately captured.
  • Identifies Special Needs Program members that requires Health Risk Assessments (HRA) and implements the facilitation of HRA completion.
  • Supports Care Management administrative needs including but not limited to case building, UM communication, and navigation of community resources.
Qualifications:
  • Bachelor’s degree
  • A minimum of 3 – 5 years’ experience in health, wellness, case management, or other related activities required
  • Experience in discharge planning or care transition interventions is desirable preferred
  • Excellent verbal and written communication skills required required
  • Computer proficiency required required
  • Experience with HEDIS preferred preferred
  • Experience with HCC coding is desirable preferred

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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