Responsibilities:* Audit, monitor and track compliance of the Utilization Management, Care Management, teams adherence to the Plan, regulatory, and accreditation requirements functions include but are not limited to appeals, case management, utilization management,. This entails reviewing reports against regulatory requirements, looking for trends, notifying management of any trends, and then tracking their responses/actions to ensure the negative trends do not continue.* Participate in planning and implementing strategies that provide direction and subsequent monitoring of the Utilization Management, Care Management, team functions including assessment of potential new processes and existing processes.* Track Utilization Management (UM), Care Management (CM), compliance using the dashboard/matrix, and other organizational and department tools including loading material for organizational use onto Sharepoint.* Training Utilization Management (UM)/Care Management (CM) departments on systems and use of applications (ie MCG, MaxMC and CCA).* Training Care Management department on process.* Development of training tools, development of training tracking process.* Coordinate training for Care Management department with external vendors as applicable.* Work with reporting area to develop and maintain reports that provide data from the system and apply it to timeframes/standards.* Regular attendance is an essential function of the job. Performs other duties as assigned or required.Qualifications:* Associates degree required, Bachelor's degree preferred* Years of experience can be substituted for years generally required for a degree* Active, unrestricted Nursing License (Registered Nurse) required* Possess at least 4 to 6 years of experience in a managed care environment including familiarity with Auditing, Accreditation, Compliance, Quality, or delegation or Utilization Management experience required* Knowledge of accreditation standards, and regulatory standards such as New York State Department of Health (NYSDOH) and Centers for Medicare & Medicaid Services (CMS) preferred* History of Training/Instructional Design preferred* Proficient in understanding and in use of Word, Excel, SharePoint, PowerPoint and Outlook, including excellent working knowledge of MS Office applications preferredAdditional Information* Requisition ID: 4535BREEOC StatementWe are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.Sponsorship StatementDepending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.
* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.