Remote utilization review nurse jobs in Rochester, New YorkCreate job alerts

Job Description: Summary: 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. Essential Accountabilities: Level I • 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. The process includes case identification, case opening, member assessment, education and support intervention opportunities, developing care plans, conducting member-centric interventions, measuring member outcomes during re-assessment, case closure, and case reviews., • Screens members that fall within the defined populations served, referred to the department, either by data analysis or by internal or external referral sources. Applies case management criteria and professional clinical judgment to determine a member's appropriateness for case management services., • Initiates case management, as outlined in the Case Management Program Description. Opens appropriate cases timely and effectively. Using motivational interviewing, assures essential information relating to case management is disclosed to members, thus increasing the opportunity for success in meeting member health goals., • Works in collaboration with members' physicians and other health care providers to assess the needs of the member, facilitate development of an interdisciplinary care plan, coordinates services, evaluates effectiveness of services and modifies the member care plan as necessary. Maintains positive working relationships within this arena., • 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. Maintains updated information related to appropriate community resources and serves as a source of information for providers and other members of the healthcare team. Acts as a liaison between providers and community resources., • Participates in inter-disciplinary coordination and collaboration to ensure delivery of consistent and quality health care services. Examples may include: Utilization Management, Quality, Behavioral Health, Pharmacy, Registered Dietitian and Respiratory Therapist, • Accepts responsibility for continuing education relative to professional growth. Meets or exceeds the minimum continuing education requirements as set forth by departmental and corporate policy, and by individual professional certification standards, if applicable., • Participates in and promotes other health plan programs, such as, Preventive Health, use of web-based tools for self-management of conditions and engagement in digital health programs and applications., • Work collaboratively with all Case Managers, especially those with varied clinical expertise (ex. Social Work, Behavioral Health, Respiratory Therapy, Registered Dietitian, Registered Nurse, Medical Director, Pharmacist, Geriatrics, etc.) to ensure continuity and coordination of care., • May work with internal and external stakeholders for value-based payment programs, such as accountable cost and quality arrangements (ACQA)., • Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs., • 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. Level II (in addition to Level I Essential Accountabilities) • Handles all member clinical condition management programs., • Offers process improvement suggestions and participates in the solutions of more complex issues/activities., • Mentors junior staff and assists with coaching whenever necessary., • Consistently meets/exceeds all productivity and performance metrics, including positive results of audits., • Works independently in coordinating and collaborating with members and providers, resulting in improving member and community health., • Manages more complex assignments and/or larger caseloads., • Displays leadership skills and serves as a positive role model to others in the department., • Participates in the orientation of new staff. Level III (in addition to Level II Essential Accountabilities) • Process Management and Documentation, • Identifies, recommends, and evaluates new processes as necessary to improve productivity and gain efficiencies., • Assists in updating departmental policies, procedures and desk-top manuals relative to the CM functions., • Identifies and develops processes and guidelines for performance improvement opportunities for the Case Management Department., • Expert and resource for escalations. Serves as subject matter expert and if called upon, works directly with the operation and clinical staff to resolve issues and escalated problems., • Mentors and provides guidance and leadership to the daily activities of the Case Management Department clinical staff. Acts as resource to Case Management staff, members, and providers., • Provides backup for the Supervisor/Manager, whenever necessary by:, • Participating in the orientation of new staff and/training opportunities for all staff. Assists staff to identify opportunities to successfully engage members into care., • Acting as a liaison for activity generated by Customer Advocacy (CAU), Customer Service (CS), Special Investigations Unit (SIU), Provider Relations (PR), or Sales & Marketing., • Ensuring all regulatory requirements are being met, such as NYS DOH, CMS, NCQA, and HEDIS, serving as internal auditor within the group., • Responsible for all aspects of the Case Management department functions including quality, productivity, utilization performance, and educational needs to address established policies and procedures and job responsibilities. Minimum Qualifications: NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities. All Levels • 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 three (3) years of either hire and/or moving into this role supporting the FEP LOB. Level II (in addition to Level I Qualifications) • A minimum of 2 years in case management position., • Case Management Certification preferred., • Delivers efficient, effective, and seamless care to members., • Demonstrates ability to escalate to management, as necessary., • Demonstrates proficiency in all related technology and documentation requirements., • Consistently meets or exceeds all performance metrics. Level III (in addition to Level II Qualifications) • Must have been in a current Case Management position or similar subject matter expert for at least 5 years., • Case Management Certification required, • Broad understanding of multiple areas (i.e. UM and CM). At this level, incumbent is required to know multiple functional areas and supporting systems., • Expertise in Case Management area and able to handle complex assignments, challenging situations, and highly visible issues., • Ability to lead the training of new staff., • Demonstrated presentation skills. Physical Requirements: • Ability to travel and work long hours on a computer., • May require flexible hours to meet needs of member discussions. In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer Compensation Range(s): Level I: E2: Minimum: $62,400 - Maximum: $ 96,081 Level II: E3: Minimum: $62,400 - Maximum: $ 106,929 Level III: E4: Minimum: $65,346 - Maximum: $117,622 The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. 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, in addition to internal equity. 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. Please note: There may be opportunity for remote work within all jobs posted by the CDPHP Talent Acquisition team. This decision is made on a case-by-case basis. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Job Description: Summary: 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. Essential Accountabilities: Level I • Handles behavioral 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. The process includes case identification, case opening, member assessment, education and support intervention opportunities, developing care plans, conducting member-centric interventions, measuring member outcomes during re-assessment, case closure, and case reviews., • Screens members that fall within the defined populations served, referred to the department, either by data analysis or by internal or external referral sources. Applies case management criteria and professional clinical judgment to determine a member's appropriateness for case management services., • Initiates case management, as outlined in the Case Management Program Description. Opens appropriate cases timely and effectively. Using motivational interviewing, assures essential information relating to case management is disclosed to members, thus increasing the opportunity for success in meeting member health goals., • Works in collaboration with members' physicians and other health care providers to assess the needs of the member, facilitate development of an interdisciplinary care plan, coordinates services, evaluates effectiveness of services and modifies the member care plan as necessary. Maintains positive working relationships within this arena., • 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. Maintains updated information related to appropriate community resources and serves as a source of information for providers and other members of the healthcare team. Acts as a liaison between providers and community resources., • Participates in inter-disciplinary coordination and collaboration to ensure delivery of consistent and quality health care services. Examples may include Utilization Management, Quality, Behavioral Health, Pharmacy, Registered Dietitian and Respiratory Therapist, • Accepts responsibility for continuing education relative to professional growth. Meets or exceeds the minimum continuing education requirements as set forth by departmental and corporate policy, and by individual professional certification standards, if applicable., • Participates in and promotes other health plan programs, such as, Preventive Health, use of web-based tools for self-management of conditions and engagement in digital health programs and applications., • Work collaboratively with all Case Managers, especially those with varied clinical expertise (ex. Social Work, Behavioral Health, Respiratory Therapy, Registered Dietitian, Registered Nurse, Medical Director, Pharmacist, Geriatrics, etc.) to ensure continuity and coordination of care., • May work with internal and external stakeholders for value-based payment programs, such as accountable cost and quality arrangements (ACQA)., • Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs., • Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures., • Regular and reliable attendance is expected and required., • Performs other functions as assigned by management. Level II (in addition to Level I Accountabilities) • Handles all member clinical condition management programs., • Offers process improvement suggestions and participates in the solutions of more complex issues/activities., • Mentors junior staff and assists with coaching whenever necessary., • Consistently meets/exceeds all productivity and performance metrics, including positive results of audits., • Works independently in coordinating and collaborating with members and providers, resulting in improving member and community health., • Manages more complex assignments and/or larger caseloads., • Displays leadership skills and serves as a positive role model to others in the department., • Participates in the orientation of new staff. Level III (in addition to Level II Accountabilities): • Process Management and Documentation - o Identifies, recommends, and evaluates new processes as necessary to improve productivity and gain efficiencies. o Assists in updating departmental policies, procedures and desk-top manuals relative to the CM functions. o Identifies and develops processes and guidelines for performance improvement opportunities for the Case Management Department. • Expert and resource for escalations. Serves as subject matter expert and if called upon, works directly with the operation and clinical staff to resolve issues and escalated problems., • Mentors and provides guidance and leadership to the daily activities of the Case Management Department clinical staff. Acts as resource to Case Management staff, members, and providers., • Provides backup for the Supervisor/Manager, whenever necessary by: o Participating in the orientation of new staff and/training opportunities for all staff. Assists staff to identify opportunities to successfully engage members into care. o Acting as a liaison for activity generated by Customer Advocacy (CAU), Customer Service (CS), Special Investigations Unit (SIU), Provider Relations (PR), or Sales & Marketing. o Ensuring all regulatory requirements are being met, such as NYS DOH, CMS, NCQA, and HEDIS, serving as internal auditor within the group. • Responsible for all aspects of the Case Management department functions including quality, productivity, utilization performance, and educational needs to address established policies and procedures and job responsibilities. Minimum Qualifications: NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities. All Levels • Active NYS RN license required with three years' behavioral health experience; or LMSW; or LCSW; or LMHC., • 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 three (3) years of either hire and/or moving into this role supporting the FEP LOB. Level II (in addition to Level I Qualifications) • A minimum of 2 years in case management position., • Case Management Certification preferred, • Delivers efficient, effective, and seamless care to members., • Demonstrates ability to escalate to management, as necessary., • Demonstrates proficiency in all related technology and documentation requirements., • Consistently meets or exceeds all performance metrics. Level III (in addition to Level II Qualifications) • Must have been in a current Case Management position or similar subject matter expert for at least 5 years., • Case Management Certification required, • Broad understanding of multiple areas (i.e. UM and CM). At this level, incumbent is required to know multiple functional areas and supporting systems., • Expertise in Case Management area and able to handle complex assignments, challenging situations, and highly visible issues., • Ability to lead the training of new staff., • Demonstrated presentation skills. Physical Requirements: • Ability to travel and work long hours on a computer., • May require flexible hours to meet needs of member discussions. In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer Compensation Range(s): Level I: E2: Minimum: $62,400 - Maximum: $ 96,081 Level II: E3: Minimum: $62,400 - Maximum: $ 106,929 Level III: E4: Minimum: $65,346 - Maximum: $117,622 The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. 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, in addition to internal equity. 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. Please note: There may be opportunity for remote work within all jobs posted by the CDPHP Talent Acquisition team. This decision is made on a case-by-case basis. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.