Registered Nurse, Care Manager - Remote with active NY license at EmblemHealth

About the position

As a Care Manager at DirectEmployers, you will play a crucial role in providing comprehensive care management as part of a multi-disciplinary care team. Your primary responsibilities will include care coordination, conducting telephonic or face-to-face assessments of members' health care needs, and identifying gaps in care and necessary support. You will be instrumental in administering and coordinating the implementation of interventions that support members in managing their physical, environmental, and psycho-social concerns. This role requires you to help members understand and effectively utilize their health plan benefits, ensuring they remain safe and independent in their home or current living environment, in collaboration with healthcare providers. You will be tasked with providing Care Management services to high-risk members within the community, which may include working in various settings such as Physician Practices, Retail Centers/Neighborhood Care Centers, and members' homes. Your goal will be to coordinate and deliver care that is safe, timely, effective, efficient, and centered around the member's needs. This involves engaging with the most complex members of the health plan to improve healthcare outcomes and ensure appropriate and timely utilization of services across the continuum of care. You will also assist the entire Care Management interdisciplinary team in managing members with Care Management needs, ensuring a holistic approach to care delivery. In this role, you will assess and evaluate the needs of our most complex members, acting as the clinical coordinator. You will collaborate with members, caregivers, providers, and community resources through various assessments to identify areas of concern and potential gaps in care. Your responsibilities will include identifying appropriate goals, strategies, and interventions, developing and communicating medical management strategies, and engaging actively with the member's primary care provider. You will also advocate for members by facilitating interventions with providers and agencies, ensuring compliance with all applicable regulations and standards, and maintaining accurate documentation in the Electronic Medical Records System (EMR).

Responsibilities

• Assess and evaluate the needs of complex members, acting as the clinical coordinator.
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• Collaborate with members, caregivers, providers, and community resources to identify areas of concern and potential gaps in care.
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• Identify appropriate goals, strategies, and interventions based on areas of concern.
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• Develop, communicate, and evaluate medical management strategies and interventions.
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• Engage actively with the member's primary care provider and treatment team.
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• Work collaboratively with stakeholders to ensure knowledge of the action plan.
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• Align member needs with the appropriate member of the care team.
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• Act as the member's advocate and liaison with providers and agencies.
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• Ensure compliance with federal and state regulations, and NCQA and company standards.
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• Participate in delegation collaboration activities as required.
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• Research evidence-based guidelines and medical protocols for care management recommendations.
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• Enter and maintain documentation in the Electronic Medical Records System (EMR).
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• Maintain an understanding of Care Management principles and program objectives.
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• Actively participate on assigned committees and complete department-mandated training.

Requirements

• Experience in care management or a related field.
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• Strong understanding of healthcare systems and community resources.
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• Excellent communication and interpersonal skills.
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• Ability to assess and evaluate complex health care needs.
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• Knowledge of federal and state regulations related to care management.
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• Experience with Electronic Medical Records (EMR) systems.

Nice-to-haves

• Certification in care management or related field.
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• Experience working with high-risk populations.
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• Familiarity with evidence-based guidelines and medical protocols.
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• Bilingual skills to communicate with diverse populations.

Benefits