RN Care Manager, NCQA Audit - REMOTE (NY RN license required)

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

Job summary

EmblemHealth is seeking a Care Manager to provide comprehensive care management within a multi-disciplinary team. You will assess high- risk members, coordinate care plans, and support members in managing health care needs, benefits, and social determinants in their home or community settings.

The role requires an RN license in NY, 4–6+ years of clinical experience, strong communication skills, and experience with care coordination.

Qualifications

• RN license in NY required (active, unrestricted)
• 4–6+ years of clinical experience
• Experience in case management/care coordination, managed care, and/or utilization management (preferred)
• Strong communication skills (verbal, written, interpersonal)
• Familiarity with Motivational Interviewing (preferred)
• Proficient in MS Office (Word, Excel, PowerPoint, Outlook)
• Experience with electronic medical records (EMR) systems
• Bilingual ability (verbal and written) preferred

Responsibilities

• Assess and evaluate needs of the most complex members with a multidisciplinary team
• Identify goals, strategies and interventions and coordinate referrals
• Develop and evaluate medical management plans with member, family and providers
• Engage with PCPs/designees and other stakeholders
• Coordinate care plans and ensure timely, safe, effective, and patient-centered services
• Ensure compliance with federal/state regulations and NCQA standards
• Enter and maintain documentation in the EMR and meet timeframes

Skills

RN license NY

Clinical experience

Care coordination

Communication skills

Motivational Interviewing

MS Office

Bilingual (preferred)

Education

Bachelor's degree

Tools

EMR systems

Job description

Summary of Position

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

• Bachelor's degree
• Active and unrestricted RN license required in NY state
• Compact nursing license preferred
• 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)
• 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)

Additional Information

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