Care Manager, Utilization Management (NYCE) - REMOTE

Summary of Position

Support the department's quality of care and cost containment. Provide utilization management as needed to ensure coordination of health care delivery. Conduct medical appropriateness evaluations of acute care hospital admissions, post-acute care requests, and selected outpatient procedures. Facilitate the achievement of quality clinical outcomes by integrated and collaborative interventions with multiple disciplines, Pre / Post Service. Ensure that members are receiving the appropriate level of care in the appropriate setting for the appropriate length of time within the established guidelines and benefit sets; Pre-service, Concurrent Review, Post-acute and Care Management. Work with interdisciplinary team to utilize the SNP members' Plan of care to achieve improved health outcomes. Provide services per the NYCE contract.

Principal Accountabilities

• Utilize MCG, CMS Guidelines, medical and administrative policies to evaluate medical necessity.
• Identify members at risk and refers for Care management and / or disease management as needed.
• Assess and evaluate member's needs, coordinate care utilizing approved criteria(s). (Include member and family discussion as necessary).

Maintain utilization time frames are met according to regulatory guidelines (i.e., initial determination decisions, adverse determination notification to providers and members).