Care Manager, Utilization Management (NYCE)

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 outpatient 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. Provide services per the NYCE contract.

EmblemHealth is one of America’s largest not-for-profit health insurers. With an 85-year legacy of serving New York communities, EmblemHealth offers a full range of commercial and government-sponsored health plans to employers, individuals, and families. We 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 85 years, our purpose as a not-for-profit is still the same — to provide quality, affordable health insurance for New Yorkers and their families. We believe in what we’re doing. And we’re looking for passionate people to join us.

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.