Summary of Position
- Support the non-clinical functions required for successful Utilization Management.
- Ensure all work assigned to or by this position is completed in appropriate timeframes and in keeping with all organizational, regulatory and legal requirements.
- Responsible for direct supervision for 5 - 8+ non-clinical staff.
- Responsible for day-to-day oversight of workload balance among team members, staff assignment planning, and reporting oversight.
- Represent the team and/or Supervisor in projects/initiatives by participating in requirements, design and development and testing sessions or other meetings as appropriate.
- Responsible for a caseload 50% of the time.
- Provide services per the NYCE contract
Principal Accountabilities
- Direct oversight of Care Specialists and Sr. Care Specialists, including 1:1 meetings and yearly performance evaluations.
- Provide oversight/mentoring of new employees with ongoing performance coaching.
- In conjunction with the Supervisor, participate in the PIP process for assigned staff. Also participate in the hiring process with the Supervisor.
- Provide direction to the team on daily work, schedules, issues, questions, etc.
- Resolve escalated or executive issues.
- Serve as subject matter expert in processes and procedures, use of system, delegated relationships that demonstrate a higher level of clinical functioning in role.
- Identify issues, escalate, and communicate with leadership to initiate problem solving.
- Ensure organizational, legal and regulatory requirements are met for work assigned to or by this position.
- Provide case review (when necessary) and assure timely notification and correspondence to facilities, members, and providers.
- Maintain a daily caseload in accordance to the productivity needs of the Total Population Health team.
- Conduct preauthorization review activities in support of clinical staff responsible for determinations, including management of benefit exclusion determinations, in accordance with departmental policies.
- Communicate authorization decisions and important benefit information to providers and members in accordance with applicable standards.
- Interact with various departments throughout the Enterprise and contribute to the resolution of interdepartmental issues.
- Lead and develop team to quickly assess and diagnose root causes.
- Research and resolve claim/referral and authorization discrepancies/issues to facilitate timely and accurate claims adjudication in compliance with company policy and regulatory requirements.
- Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager.
- Work collaboratively with delegates to promote and maintain all established processes, policies and relationships.
- Work collaboratively with senior leadership as a critical component of the multi-disciplinary team to facilitate all nonclinical processes and activities.
- Train and develop assigned staff under the direction of the Manager/Lead.
- Perform other related projects and duties as assigned or required.
Qualifications Education, Training, Licenses, Certifications Bachelor's degree Relevant Work Experience, Knowledge, Skills, and Abilities
- 3 - 5+ years' experience in managed care, preferably in UM ops for multiple lines of business/authorization processes.
- Experience in non-clinical prior authorization/care management and/or utilization management.
- 1-year internal (company) experience.
- Additional experience/specialized training may be considered in lieu of educational requirements.
- Equivalent external experience may be considered in lieu of the one-year enterprise experience.
- Experience associated with discharge planning, care transition interventions, standard quality measures and/or prior authorization.
- Strong knowledge of medical terminology, ICD and CPT coding.
- Knowledge of community health, social service agencies and other community.
- Strong oral and written communication, organizational, analytical and interpersonal skills.
- Ability to establish priorities, work independently and proceed with objectives without direct supervision.
- Must manage a flexible work schedule to meet member and/or caregiver and departmental scheduling needs.
- User experience in a highly automated environment with strong personal computer literacy on Windows.
- Bilingual in English/Spanish.
- Expertise in customer service, data entry, non-clinical review, routing, etc. and competency in multiple areas of focus, such as acute care, home care, prior authorization, UM experience etc.
- Must be in role for 1-year by the Enterprise to qualify for the role.
- Requires coverage on weekends and holidays as needed.
Additional Information
- Requisition ID: 1000002695
- Hiring Range: $56,160-$99,360
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EmblemHealth
Sep 05, 2025