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.

Supervisor, Medical Management Operations

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Manager & Professional
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2002K Requisition #
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Direct supervision of the Medical Management Operations Concurrent Review utilization management clinical and non-clinical staff, ensuring accurate administration of benefits, execution of clinical policy and timely access to appropriate levels of care.

 

Responsibilities:

  • Under the direction of the Manager, is responsible for the execution of efficient departmental processes designed to manage inpatient utilization within the benefit plan.

  • Contributes to the overall success by promoting /advancing the department mission of effectively facilitating care and improving inpatient concurrent review outcomes.

  • Responsible for the supervision of the clinical and non-clinical staff, ensuring the timely and appropriate execution of day-to-day inventory and quality management of inpatient concurrent reviews.

  • Evaluates trends of inpatient volume across facilities, aligning staff accordingly to handle case load. Performs ongoing analysis to make recommendations to the department manager regarding volume, case type, longevity and acuities of inpatient stays.

  • Fosters development and maintenance of facility case management/UM department relationships with the internal concurrent review team by establishing and maintaining clinical staff alignment to assigned facilities.

  • Ensures that staff adhere to the proper entry and maintenance of documentation in the Medical Management platform meeting defined timeframes and performance standards, including the communication of concurrent decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, and NCQA and business standards.

  • Tracks and reports statistics on care management and/or utilization management activities, process measures (e.g. timeliness), quality results, and other measures that affect departmental objectives.

  • Organizes after-hour and weekend coverage, as required.

  • Coach and mentor to staff to ensure understanding of utilization management concepts and effectively apply the concepts to managing members’ health care needs.

  • Ensures compliance with State, Federal and NCQA requirements related to utilization management activities.

  • Under the direction of the Manager; trains, evaluates and develops assigned staff.
    Develops, monitors, and communicates performance expectations and plans for all direct reports and conducts performance reviews within specified timeframe. Provides feedback on a regular basis. Assists with resolution of employee performance issues.

  • Maintains an environment of quality improvement through continuous evaluation of processes and policies. Identifies and recommends new technologies and process efficiencies.

  • Interacts with various departments throughout the organization and contributes to the resolution of interdepartmental issues. Leads and develops team to quickly assess and diagnose root causes to problem areas.

  • Actively participates on assigned committees and projects.

  • Performs duties of a care manager or utilization manager as needed.

  • Performs other duties as assigned.

Qualifications:

  • Bachelor’s Degree in Nursing, health care, or business, or an equivalent combination of education and experience

  • RN, licensed in Connecticut

  • At least 4-6 years of clinical experience required

  • At least 2 years of managed care experience preferred

  • Supervisory experience preferred

  • State of the art knowledge of care management tactics required

  • Strong oral and written communication and interpersonal skills required

  • Strong organizational skills required

  • Strong knowledge of Microsoft Office products including Word, Excel, and Access required

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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