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.

Sr. Program Specialist

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Manager & Professional
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200LM Requisition #
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Manage the documentation in support of the operations of Care Management and the Care Management Committee to include the Operational Processes, C-More and other UM documentation.  Provide oversight of Utilization and Case Management audit activities and monitor plans of correction.  Provides oversight of audits on medical cases and timelines, as necessary

 

Responsibilities:

         Oversees the Utilization Management and Case Management Delegation Oversight Audit function.  This  includes assigning and participating in delegate file review and document review, report writing and Improvement Action plan documentation and monitoring,  monitoring the delegation oversight audit calendar, involvement with analysis of delegate reports, review of delegate management report requirements, review of delegate materials for regulatory and accreditation requirements, and presenting results to the Delegation Oversight Committee.

         Oversees development and delivery of departmental systems and administrative training.   Obtain and maintain McKesson certification, and provide train the trainer sessions, as necessary. 

         Participates in projects relating to departmental goals.  Projects normally include preparation for various new, or ongoing audits or applications, and implementation of various initiatives to ensure compliance with regulatory or accreditation requirements. 

         Creates goals and identifies opportunities in the development of annual documents to support internal and external expectations.  

         Oversees the preparation of these documents for the Care Management Committee’s review and approval and ensures compliance with accreditation and regulatory requirements. Recommends updates to documents for changes in regulations and/or work processes based on systems, regulatory and business requirements.

         Provides the continuity in the development and implementation of policies, operational processes and workflows to execute organizational strategies and to assure consistency in process application throughout Care Management.   

         Monitors adherence to implemented policies, procedures, workflows and processes.  Recommends updates to documents for changes in regulations and/or work processes based on systems, regulatory and business requirements.

         Other duties as assigned.

 

 Qualifications:

·       Bachelor’s Degree

·       RN/LPN required

·       Minimum of four years in managed care with medical operational responsibility.  

·       Regulatory, compliance and/or accreditation and / or delegation oversight experience required.

·       Strong related experience with regulatory and medical management operations may be substituted for clinical background

·       Strong organizational skills with attention to detail

·       Excellent written and oral communication skills

·       Ability to work well in groups and independently

·       Knowledge of regulatory and accreditation requirements

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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