Pediatric Care Manager Nurse (RN/NY License) - Remote

About the role

EmblemHealth is one of the nation’s largest not-for-profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources.

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.
• 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 stakeholders 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.
• Cook up 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
• Certification in Care Management (CCM) preferred
• 4 – 6+ years of clinical experience
• Organization/prioritization ability; and the ability to effectively manage a caseload of highly complex members
• Support an integrated care model tapping into appropriate resources both internally and external to the organization
• Experience in case management/care coordination, managed care, and/or utilization management
• Strong communication skills (verbal, written, presentation, interpersonal)
• Trained in the use of Motivational Interviewing techniques
• Experience working in medical facility or practice and/or with electronic medical records
• Computer proficiency: MS Office (Word, Excel, Powerpoint, Outlook); mobile technology (wireless phone/laptop, etc.)
• System user experience in a highly automated environment
• Bilingual ability (verbal, written)
• Strong cross-group collaboration, teamwork, problem solving, and decision-making skills
• Ability to work a flexible schedule (evenings, weekends and holidays) to meet member and/or caregiver and departmental scheduling needs

Benefits

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement.