Care Manager, NCQA Complex Disease Mgmt (Remote/NY)

EmblemHealth; New York (NY); Remote; USD 68,000 - 119,000; Full time

Job summary

EmblemHealth is seeking a Care Manager to join our NCQA Complex Disease Management program. The role supports high-risk members through a multi-disciplinary care approach, including telephonic and in-home assessments, care planning, and coordinating with physicians, facilities and social resources to improve outcomes.

You will work within a remote/NY framework, coordinating with care teams to ensure safe, timely and cost-effective care, while maintaining member-centered focus in diverse

Qualifications

• Active and unrestricted RN license required in NY state.
• CCM certification preferred.
• 4–6+ years of clinical experience (Required).
• Organization/prioritization ability; and the ability to effectively manage a caseload of highly complex members (Required).
• Experience in case management/care coordination, managed care, and/or utilization management (Preferred).
• Computer proficiency: MS Office (Word, Excel, Powerpoint, Outlook); mobile technology (Required).
• System user experience in a highly automated environment (Required).
• Strong cross-group collaboration, teamwork, problem solving, and decision-making (Required).

Responsibilities

• Assess and evaluate the needs of our most complex members, coordinating with a multi-disciplinary team to identify gaps in care.
• Identify goals, strategies and interventions including referrals and health education.
• Develop, communicate and evaluate medical management strategies and interventions with the care team.
• Engage with the member and family as appropriate.
• Coordinate with PCPs and care team to set attainable goals.
• Ensure documentation in the EMR and compliance with regulations.

Skills

RN license NY

CCM certification

Clinical experience 4–6+ years

Organization/prioritization

MS Office proficiency

Care management/case coordination

Flexible schedule availability

Bilingual (preferred)

Tools

EMR systems

Job description

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com .

Need Assistance Applying? EmblemHealth provides reasonable accommodations to individuals with disabilities throughout the application and hiring process. If you need an accommodation, please contact [e-mail] so we can support your request in accordance with applicable law.

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Care Manager, NCQA Complex Disease Mgmt (Remote/NY)

Provide care management, as part of a multi-disciplinary care team, that includes care coordination, performing telephonic or face-to-face assessments of members’ health care needs, identifying gaps in care and needed support, administering/coordinating implementation of interventions.Support and enable members to manage their physical, environmental and psycho-social concerns, understand and appropriately utilize their health plan benefits and remain safe and independent in their home or current living environment in collaboration with health care providers. Provide Care Management services to identified high risk members within the community, including but not limited to Physician Practices, Retail Centers/Neighborhood Care Centers, and members’ homes. Coordinate and provide care that is safe, timely, effective, efficient and member-centered to support population health, transitions of care, and complex care management initiatives.Engage with the most complex members of the health plan with the goal of improving health care outcomes and appropriate and timely utilization of services across the continuum of care.Assist the entire Care Management interdisciplinary team in managing members with Care Management needs.

Principal Accountabilities

• Assess and evaluate the needs of our most complex members, acting as the clinical coordinator collaborating with members, caregivers, providers, multi-disciplinary team, and health care and community resources through a variety of assessments to identify areas of (medical, financial, environmental, health insurance benefit, psycho-social, caregiving) concerns and potential gaps in care utilizing the most appropriate resources to support members’ needs.
• Identify appropriate goals, strategies and interventions that may include referrals, health education, activation of community-based resources, life planning, or program/agency referrals based on areas of concern.
• Develop, communicate and evaluate medical management strategies and interventions including potential for alternative solutions to ensure high quality, cost effective continuum of care with the member, caregiver, provider(s) and multidisciplinary team.
• Include member and family as appropriate.
• Engage actively with the member PCP / designee.
• Engage with the member in support of their treatment team to identify and establish attainable goals that positively impact clinical, financial, and quality of life outcomes for member.
• Work collaboratively with all stake holders to ensure knowledge of the action plan, including participation in telephonic and face-to-face case conferences when appropriate.
• Assess the needs of members and align them with the appropriate member of the care team (wellness team, registered dietitian, social worker, community health workers).
• Act as the member’s advocate and liaison by completing or facilitating interventions with providers and/or private, non-profit, and governmental agencies.
• Ensure that all Care Management processes and reporting are compliant with all applicable federal and state regulations, and NCQA and company standards.
• Participate in delegation collaboration activities, as required.
• Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making care management recommendations.
• Enter and maintain documentation in the Electronic Medical Records System (EMR), meeting defined timeframes and performance standards.
• Maintain an understanding of Care Management principles, program objectives and design, implementation, management, monitoring, and reporting.
• Actively participate on assigned committees.
• Attend and complete all department-mandated training as well as satisfy educational in-service requirements.
• Perform other related projects and duties as assigned.
• Provide ongoing monitoring, evaluation, support and guidance to the coordination of the member's health care.
• Develop, implement and coordinate plan of care and facilitate members’ goals.
• Coordinate interdisciplinary team tasks and activities, with the goal of maintaining team performance and high morale.

Qualifications

• Active and unrestricted RN license required in NY state
• CCM certification preferred
• 4 – 6+ years of clinical experience (Required)
• Organization/prioritization ability; and the ability to effectively manage a caseload of highly complex members (Required)
• Support an integrated care model tapping into appropriate resources both internally and external to the organization (Required)
• Experience in case management/care coordination, managed care, and/or utilization management (Preferred)
• Trained in the use of Motivational Interviewing techniques (Preferred)
• Experience working in medical facility or practice and/or with electronic medical records (Preferred)
• Computer proficiency: MS Office (Word, Excel, Powerpoint, Outlook); mobile technology (wireless phone/laptop, etc.) (Required)
• System user experience in a highly automated environment (Required)
• Bilingual ability (verbal, written) (Preferred)
• Strong cross-group collaboration, teamwork, problem solving, and decision-making skills (Required)
• Ability to work a flexible schedule (evenings, weekends and holidays) to meet member and/or caregiver and departmental scheduling needs (Required)

Additional Information

• Requisition ID: 1000003362
• Hiring Range: $68,040-$118,800

Security Disclosure

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Pay Disclosure

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.

EEOC Statement

We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.

Sponsorship Statement

At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.