Nurse Care Manager - NCQA (NY License Required)

EmblemHealth; New York (NY); On-site; USD 80,000 - 150,000; Full time

Job summary

EmblemHealth is seeking a Nurse Care Manager to provide comprehensive care management services as part of a multi-disciplinary team. This role involves assessing members' healthcare needs, developing care plans, and ensuring compliance with regulations. Ideal candidates should have an RN license and experience in care coordination, with strong communication and organizational skills.

Benefits

Medical insurance

Vision insurance

401(k)

Disability insurance

Qualifications

• 4 – 6 years of clinical experience required.
• Strong communication skills - verbal, written, presentation, interpersonal.
• Experience in case management/care coordination preferred.

Responsibilities

• Assess and evaluate the needs of complex members.
• Coordinate care with multidisciplinary teams.
• Advocate for members and facilitate interventions with providers.

Skills

Organization

Communication

Teamwork

Problem Solving

Education

RN license

CCM certification

Certified Diabetes Care and Education Specialist (CDCES)

Job description

Nurse Care Manager - NCQA (NY License Required)

Nurse Care Manager - NCQA (NY License Required)

3 days ago Be among the first 25 applicants

Direct message the job poster from EmblemHealth

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.

Responsibilities

• 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

• RN required, with current active RN license (Required)
• CCM certification (Preferred)
• Certification in utilization or care management (Preferred)
• 4 – 6 years of clinical experience (Required)
• Certified Diabetes Care and Education Specialist (CDCES) designation and experience (Preferred)
• 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)
• Strong communication skills - verbal, written, presentation, interpersonal (Required)
• 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)

Seniority level

• Seniority level

  Associate

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider and Consulting

• Industries

  Insurance

Referrals increase your chances of interviewing at EmblemHealth by 2x

Inferred from the description for this job

Medical insurance

Vision insurance

401(k)

Disability insurance

Get notified about new Nursing Manager jobs in New York, United States.

Nurse Care Manager-NCQA Focus/NY License Required - (Remote)

New York, NY $94,000.00-$150,000.00 4 weeks ago

New York, United States $77,760.00-$149,040.00 1 month ago

New York, United States $80,000.00-$100,000.00 1 week ago

Registered Nurse-Multispecialty-Hicksville, NY-Full Time-Day-Offsite

New York, NY $107,363.00-$123,866.00 4 weeks ago

Registered Nurse-Multispecialty-Hicksville, NY-Full Time-Day-Offsite

New York, NY $107,363.00-$123,866.00 5 months ago

Remote RN Telephone Triage (NYS license required)

Williamsville, NY $34.00-$35.00 8 months ago

Virtual Chronic Care Management Nurse (Contractor)

New York, United States $90,000.00-$100,000.00 1 week ago

REMOTE F/T OVERNIGHT RN TELEPHONE TRIAGE (NYS LICENSED)

New York, United States $26.50-$47.59 4 hours ago

RN Medical/Surgical Tele-Registered Nurse

Rochester, NY $2,101.46-$2,101.46 5 days ago

NON-COMPACT STATE - PT Remote CCM/RTM Care Management Nurse (CA)

Clinical Review Nurse - Prior Authorization

New York, United States $26.50-$47.59 22 hours ago

Clinical Documentation Specialist (Registered Nurse) - Remote

Great Neck, NY $78,000.00-$130,000.00 1 day ago

Albany, NY $77,969.00-$141,371.00 1 week ago

Care Management Nurse (NY License Required) - REMOTE

Full-Time Virtual Registered Nurse (Temp)

Registered Nurse Advisor at Healthcare Venture Capital Fund - Healthcare Shares

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.