Case Manager, Medicaid Long Term Support Program

At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration.

At MVP Health Care, we’re on a mission to create a healthier future for everyone – which requires innovative thinking and continuous improvement. To achieve this, we’re looking for a Case Manager, Medicaid Long Term Support Program to join #TeamMVP. If you have a passion for advocacy, collaboration and problem solving and innovation this is the opportunity for you. What’s in it for you: Growth opportunities to uplevel your career A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team Competitive compensation and comprehensive benefits focused on well-being An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work for and one of the Best Companies to Work For in New York This position may be worked either virtually (worked remotely from home) within a New York residency or at one of our office locations (Schenectady, Rochester, Tarrytown).

Utilize the essentials of an integrated utilization management and case management model that includes assessment, planning, implementation, care coordination, monitoring, and advocacy to meet the needs of medically complex Medicaid members. Through collaborative efforts the Case Manager will identify the medical and psycho-social needs of designated members, act as a proactive partner, and provide appropriate education, coordination of care and resource allocation. The principal role of the position is to engage individual members and communicate with an established interdisciplinary team. The role requires review of a comprehensive assessment and development of a time tasking tool and an individualized person-centered plan of care. The position will provide guidance in understanding benefit coverage and navigating the health care delivery system. The overall objective is to create solutions to overcome barriers to care and assist the member to achieve optimum health and/or improved functional capability through the coordination of quality cost effective care. The Case Manager will also monitor and review cases with the Medical Director to ensure appropriate outcomes. Service Authorization & Review: Conduct prospective, concurrent, and retrospective reviews to determine medical necessity and appropriateness of LTSS services. Care Coordination: Collaborate with case managers, care coordinators, and providers to ensure integrated, person-centered care. Compliance & Quality: Ensure adherence to Medicaid, Medicare, and accreditation standards (e.g., NCQA), including documentation and reporting. Cost Management: Monitor service utilization to maintain cost-effectiveness and manage Medical Loss Ratio (MLR). Appeals & Denials: Participate in the appeals process for denied services and ensure timely resolution. Training & Support: Educate staff and providers on UM protocols, documentation standards, and clinical guidelines. Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer.