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 two (2) years of either hire and/or moving into this role supporting the FEP LOB.
• For incumbents aligned to Hospital to Home program only, active NYS RN license required with three years’ behavioral health experience; or LMSW; or LCSW; or LMHC required.

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.
• Carries out job responsibilities in accordance with departmental, corporate, state, federal and accreditation standards, as well as licensure, certification and scope of practice requirements for each specific health-related field/specialty.
• Maintains confidentiality and conducts information management procedures per corporate and departmental policy.
• 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 to address knowledge deficits.
• Collaborates with member/caregiver to determine specific objectives, goals and actions to address member needs and barriers to meeting health goals identified during assessment.
• 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.
• Works collaboratively with all Case Managers.
• May work with internal and external stakeholders for value-based payment programs.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values.
• 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: Grade E2: Minimum: $62,400 - Maximum: $96,081
• Level II: Grade E3: Minimum: $62,400 - Maximum: $106,929
• Level III: Grade E4: Minimum: $65,346 - Maximum: $117,622
• Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications.
• The posted salary range reflects just one component of our total rewards package.
• 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 may be available on a case-by-case basis.