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 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.
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.
Qualifications Education, Training, Licenses, Certifications
- Associate Degree in Nursing; Bachelor's preferred.
- RN with an active, unrestricted nursing license (Concurrent Review, Medical Management, etc.)
- LPN with an active, unrestricted nursing license (Prior Authorization, Discharge Planning, Retrospective Review)
- 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: 1000002687
- Hiring Range: $68,040-$118,800
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EmblemHealth
Sep 05, 2025