28 days old

Care Manager - Utilization Management

Emblem Health
Albany, NY 12207
  • Job Code
Summary of Position

Support the department's quality of care and cost containment.
Provide utilization management as needed to ensure coordination of health care delivery.
Conduct medical appropriateness evaluations of acute care hospital admissions, post-acute care requests, and selected out-
patient procedures.
Facilitate the achievement of quality clinical outcomes by integrated and collaborative interventions with multiple disciplines,
Pre/Post Service.
Ensure that members are receiving the appropriate level of care in the appropriate setting for the appropriate length of time
within the established guidelines and benefit sets; Pre-service, Concurrent Review, Post-acute and Care Management. Work
with interdisciplinary team to utilize the SNP members' Plan of care to achieve improved health outcomes.

Principal Accountabilities

Utilize MCG, CMS Guidelines, medical and administrative policies to evaluate medical necessity.
Identify members at risk and refers for Care management and/or disease management as needed.
Assess and evaluate member's needs, coordinate care utilizing approved criteria(s). (Include member and family discussion as necessary).
Maintain utilization time frames are met according to regulatory guidelines (i.e., initial determination decisions, adverse determination notification to providers and members).
Provide appropriate case review; ensure timely notification and correspondence to facilities, members and providers.
Utilize the member's contract to determine coverage eligibility. Work with providers and take action in problem solving while exhibiting judgment and a realistic understanding of the issues.
Prepare and present clinical detail to the Medical Director for final case determination in accordance with regulation and department policy.
Ensure cost effectiveness and identified opportunities to reduce cost are captured (i.e. reinsurance reporting).
Refer to Medical Director any questionable quality issues or inappropriate hospitalizations for immediate intervention and/or refer cases that do not meet established criteria for approval of selected procedure or service.
Regular attendance is an essential function of the job. Perform other duties as assigned or required.

Education, Training, Licenses, Certifications
Associate Degree in Nursing; Bachelor's preferred.
RN with an active, unrestricted nursing license (Concurrent Review, Medical Management, etc.)
MCG Certification preferred

Relevant Work Experience, Knowledge, Skills, and Abilities
4 - 6 years of clinical experience.
Managed care experience.
Post-acute facility experience.
Care management experience.
Ability to work weekends and holidays on a rotating schedule.
Excellent communications skills (verbal, written, presentation, interpersonal).
Effectively able to screen and stratify members who are appropriate for care management services.
Ability to: manage a caseload of members in need of care management; and apply the care management process as outlined
by the CMSA standards and EH's policies.
Ability to make appropriate referrals to internal and external programs that meet the member's needs.
Ability to create and execute care management care plans and document per EH's policies and procedures.
Ability to speak professionally with all necessary parties associated with the member's care plan.

Additional Information

  • Requisition ID: 1000000355

Posted: 2022-07-15 Expires: 2022-08-13
Sponsored by:
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Sponsored by:
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Care Manager - Utilization Management

Emblem Health
Albany, NY 12207

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