Senior Care Manager - RN, LPN, PA Clinical Exerience Needed!
CARE MANAGER – New York City, NY
(RN, LPN, PA with 3-5 years clinical experiece required!)
Supports the department’s quality of care and cost containment. Provides utilization management as needed to ensure coordination of health care delivery. Conducts medical appropriateness evaluations of hospital admissions and selected out-patient procedures. Facilitates the achievement of quality clinical outcomes by intergrated and collaborative interventions with multiple disciplines, Pre/Post Service. Ensures that members are receiving the appropriate level of care in the appropriate setting for the appropriate length of time within the established guidelines and benefit sets, Pre-service, Concurrent Review, Post Acute and Care Management. Work with interdisciplinary team to utilize the SNP members’ Plan of care to achieve improved health outcomes.
• Utilizes the member’s contract to determine coverage eligibility. Works with providers and take action in problem solving while exhibiting judgment and a realistic understanding of the issues.
• Utilizes InterQual Criteria, CMS Guidelines, medical and administrative policies to evaluate medical necessity.
• Prepares and presents clinical detail to the medical Director for final case determination in accordance with regulation and department policy.
• Ensures cost effectiveness and identifies opportunities to reduce cost are captured (i.e. reinsurance reporting)
•Identifies members at risk and refers for Care management and/or disease
management as needed. Assesses and evaluates member’s needs, coordinate care
utilizing approved criteria(s). Includes member and family discussion as
• Refers to Medical Director any questionable quality issues
or inappropriate hospitalization for immediate intervention and /or refer cases
that do not meet established criteria for approval of selected procedure or
• Maintains utilization time frames are met according to
regulatory guidelines (i.e., initial determination decisions, adverse
determination notification to providers and members). Provides case review
(when necessary) and assures timely correspondence to facilities, members, and
Position Success Criteria:
• Effectively able to screen and stratify members who are appropriate for care management services.
• Able to manage a caseload of members who are in need of care management and ability to apply the care management process as outlined by the CMSA standards and EH’s policies.
• Makes appropriate referrals to internal and external 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 speak professionally with all necessary parties associated with the member’s care plan.
Education and Experience:
• RN, LPN PA with two to four years of college.
• Three to five years of clinical experience (all professionals must be licensed in New York State).
• Managed care experience preferred.
• Care management experience desirable.
• Excellent written and oral communication skill.
For Immediate Consideration, please email your resume - email@example.com