Care Manager, UM (NYCE) - REMOTE

EmblemHealth is a leading health care organization whose companies provide insurance plans and primary and specialty care. As one of the nation’s largest not-for-profit health insurers, we serve communities across New York State. EmblemHealth started back in the 1930s, at the height of the Great Depression. Out of hard times, the idea of health insurance was born: a system that would protect everyday people from financial misfortune if they had an accident or illness. Two companies from those early days of health insurance, Group Health Incorporated (GHI) and Health Insurance Plan of Greater New York (HIP), would later merge and become EmblemHealth. And after 80 years, our mission is still the same: to create healthier futures for our customers and communities

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.

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.