Care Manager, LTSS Enrollment (RN NY License Required)

Summary of Position

Coordinate intake functions with New York Independent Assessor (NYIA) clinical program for members who are requesting LTSS program enrollment. Complete Time Tasking Tool (TTT) for members who have a NYIA)/Maximus finalized assessment in the Uniform Assessment System (UAS). Facilitate the Expedited Assessment & TOC Immediate Need Form process with member and Operational Support Unit (OSU). Submit the plan of care to the IA for members who meet criteria for more than 12 hours per day/24 hours in a 7-day week for new program members. Complete the Community Health Assessment (CHA) Variance Resolution (clinical dispute process) between NYIA and EmblemHealth via the CHA Variance Form. Support clinical intake review of program members in relation to the UAS assessment process for reassessments, change of condition, care transitions and new program members. Coordinate and facilitate determinations and outliers with EH Medical Directors based on outcome of UAS assessments and program eligibility.

Responsibilities:

• Conduct quality assurance review of completed UAS assessments in care management database for EmblemHealth managed LTSS members.
• Coordinate the Independent Review Panel (IRP) process for members who task 12+ hours of care, reconciles and processes determinations received back from the (IRP) in relation to scope/type and durations of services.
• Collaborate with member, caregiver, Maximus, and the plan to ensure three-way calls are completed within six days of request for initial assessments and expedited assessments.
• Submit completed forms timely to the NYIA via a secure weblink; complete member and provider correspondence including verbal outreach in accordance with departmental and DOH guidelines.
• Maintain knowledge of all applicable NYSDOH/CMS guidelines and relevant organizational and departmental policies and procedures.
• Escalate questions or concerns during the program assessment and enrollment process to the leadership team and or NYIA to ensure proper completion of UAS-NY and handling of issues that may require intervention.
• Support an integrated care model tapping into appropriate resources both internally and external to the organization.
• Enter and maintain documentation in the Electronic Medical Records System (EMR), meeting defined timeframes and performance standards.
• Maintain an understanding of Care Management principles, program objectives and design, implementation, management, monitoring, and reporting.
• Actively participate on assigned committees and meetings to support LTSS program functions.
• Attend and complete all department-mandated training as well as satisfy educational in-service requirements.
• Perform other related projects and duties as assigned.
• Act as the member's advocate and liaison by completing or facilitating interventions with providers and/or private, non-profit, and governmental agencies.