Role Description Conducts case management program activities in accordance with departmental, corporate, NYS Department of Health (DOH), Centers for Medicaid & Medicare Services (CMS), Federal Employee Program (FEP) and National Committee for Quality Assurance (NCQA) accreditation standards, as appropriate to the member’s case assignment. Uses a systematic approach to identify members meeting program criteria; assessing for opportunities to educate, support, coach, coordinate care and review treatment options, through collaboration with providers and community-based resources. Participates in a cross functional, multi-disciplinary team to identify and implement member-centric interventions to ensure optimal and cost-effective health outcomes. Collaborates with interdisciplinary care team to develop a comprehensive care plan to identify key strategic interventions to address member’s needs, health goals and mitigate health care cost drivers.

Qualifications

• Associates degree required. Bachelor’s degree preferred.
• Active NYS RN or Registered Dietician or Physical Therapist licensure required.
• Minimum of three years of clinical experience required. Case Management experience preferred.
• Must demonstrate proficiency with the Microsoft Office Suite.
• Experience in interpreting managed care benefit plans and strong knowledge of government program contracts (Medicare and Medicaid) and benefits, preferred.
• Strong written and verbal communication skills.
• Ability to multitask and balance priorities.
• Must demonstrate ability to work independently on a daily basis.
• Deliver efficient, effective, and seamless care to members.
• For incumbents aligned to the Federal Employee Program (FEP) line of business, Case Management Certification required within three (3) years of either hire and/or moving into this role supporting the FEP LOB.

Requirements

• Handles physical health member clinical management programs.
• Maintains knowledge of current Case Management Society of America (CMSA) Standards, NCQA Standards, Case Management Program activities, and performs the activities as directed by departmental policy and leadership, current NYS DOH, CMS regulations and standards if managing members of Medicare programs, and other regulatory requirements as applicable.
• Implements the Case Management Process per department policies, procedures and guidelines.
• Screens members that fall within the defined populations served, referred to the department, either by data analysis or by internal or external referral sources.
• Initiates case management, as outlined in the Case Management Program Description.
• Works in collaboration with members’ physicians and other health care providers to assess the needs of the member.
• Assesses member/caregiver knowledge of his/her illness and initiates appropriate education interventions.
• Collaborates with member/caregiver to determine specific objectives, goals and actions to address member needs.
• Provides appropriate resources and assistance to members with regards to managing their health across the continuum of care.
• Participates in inter-disciplinary coordination and collaboration to ensure delivery of consistent and quality health care services.
• Accepts responsibility for continuing education relative to professional growth.
• Participates in and promotes other health plan programs.
• Work collaboratively with all Case Managers.
• May work with internal and external stakeholders for value-based payment programs.
• Consistently demonstrates high standards of integrity.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• May participate in the orientation of new staff.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Benefits

• Compensation Range(s):
• Level I: E2: Minimum: $62,400 - Maximum: $96,081
• Level II: E3: Minimum: $62,400 - Maximum: $106,929
• Level III: E4: Minimum: $65,346 - Maximum: $117,622
• Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.
• Opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team.

Company Description

Equal Opportunity Employer