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.
RN Care Manager, Medical Management Operations
🔍 New York, New York
Summary of Job
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.
Responsibilities:
- 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:
- 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
- 4 – 6+ years of Nursing experience (Required)
- Case and/or utilization management/care coordination and managed care experience (Preferred)
- Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience (Required)
- Organizing and prioritizing skills, and strong attention to detail (Required)
- Trained in the use of Motivational Interviewing techniques (Preferred)
- Experience working in physician practice and/or with electronic medical records (Preferred)
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) (Required)
- Proficiency with the use of mobile technology (Smartphone, wireless laptop, etc.) (Required)
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
EmblemHealth may provide work visa sponsorship depending on factors such as business unit requirements, position nature, costs, and applicable laws and regulations.