Manager, Complex Case Management
EmblemHealth - New York, NY

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Summary of Position:
Responsible for the day-to-day operation and performance of specific functional areas within the compliance with health plans policies, procedures and all regulatory mandates, consistent with health plans mission, vision, purpose and value statements. The Case Management Supervisor is responsible for continuously improving the effectiveness and efficient operations of the Case Management Unit with Medical Management. The incumbent will continuously audit charts and files to ensure that documentation meets NCQA regulations. Incumbent will also function as a resource for the management staff to maximize quality of standards of care and appropriate utilize resources. Works with other departments to maximize cooperative relationships and acts as an interface with others for excellent customer service and process improvement.

Principal Accountabilities:
• Identifies high risk, high cost cases where intervention will provide quality care and reduce cost.
• Assesses the members’ needs by review of medical records and contact with proper resources.
• Formulates plan of care and establishes appropriate and cost effective goals for members in collaboration with their health care team.
• Provides ongoing monitoring, evaluation, support, and guidance in coordinating the member’s care.
• Documents all pertinent information pertaining to members’ progress and management of care.
• Acts as a resource for case managers and others as needed.
• Submits periodic written reports, as required, with cost analyses.
• Performance will be measured specifically by appropriateness of staffing, case loads, cost of staffing plan, appropriateness of tools for employees, timeliness and appropriateness of response to vendors, providers and members; improved effectiveness and efficiency of the process and member, provider and employee satisfaction.

Education & Experience:
• BSN required.
• Strong problem-solving ability.
• Excellent written and oral communication skills.
• Computer proficiency required.
• Registered Nurse with a minumum five years to 8 years clinical experience and a current New York State license and/or Connecticut license depending on assignment
• Previous managed care experience, which include administrative responsibilities
• Must have supervisory experience.