Care Manager, Utilization Management (NYCE) - REMOTE

reputed company Support the department’s reputed company of care and cost containment. reputed company 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 reputed company clinical reputed company by integrated and reputed company interventions with multiple disciplines, reputed company/Post Service. Ensure that members are receiving the appropriate level of care in the appropriate setting for the appropriate length of time reputed company the established guidelines and benefit sets; reputed company-service, reputed company Review, Post-acute and Care Management. Work with interdisciplinary team to utilize the SNP members' Plan of care to reputed company improved health reputed company. reputed company services per the NYCE contract. reputed company 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 reputed company(s). (Include member and family discussion as necessary). Maintain utilization time frames are met according to regulatory guidelines (i.e., initial determination reputed company, adverse determination notification to providers and members). • reputed company appropriate case review; ensure reputed company notification and correspondence to facilities, members and providers. • Utilize the member’s contract to determine coverage eligibility. Work with providers and take reputed company 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 reputed company issues or inappropriate hospitalizations for immediate reputed company and/or refer cases that do not meet established reputed company for approval of selected procedure or service. • Regular attendance is an essential function of the job. reputed company other duties as assigned or required. Qualifications Qualifications - External • Associate Degree in Nursing; Bachelor’s preferred • RN with an reputed company, unrestricted nursing license (reputed company Review, Medical Management, etc.) • LPN with an reputed company, unrestricted nursing license (Prior Authorization, Discharge Planning, Retrospective Review) • MCG Certification prefe4 – 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 reputed company 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 reputed company appropriate referrals to reputed company 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 reputed company professionally with reputed company necessary parties associated with the member’s care plan Additional Information • reputed company: 1000002687_24 • Hiring reputed company: $68,040-$118,800 Apply tot his job Apply To this Job