Company Description

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Job Description

Coordinate Home Infusion services that achieve optimal benefit and results from the comprehensive management of members with chronic and/or catastrophic illness, members who are frail elderly and/or members whose illness is complicated by challenging psychosocial conditions. Provide focus on transition activities to benefit clinical needs of members. Combine utilization of medical care and pharmacy, with specific focus on the transition of care needs of members from one setting to another and the inpatient setting (acute, SNF/Rehab) to the home setting to ensure coordination of health care delivery, member education, and preventative intervention. Support the site of care that meets the needs of members at the lowest cost.

Requirements

• Graduate of an accredited 2–4 year nursing program • Active, unrestricted license to practice professional nursing, RN (Preferred) or LPN, in the appropriate state • Certification as a Case Manager (Preferred) • 5 – 10+ years of clinical experience in a managed care setting, preferably including acute care experience (Required)) • Ability to use data analytics to drive decision making and strategy (Preferred) • Experience leading clinical staff (Preferred) • Prior case management experience (Preferred) • Communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required) • Proficient with MS Office - Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc. (Required) • Discharge planning experience (Required)

Responsibilities

• Provide short term care coordination with members, physician, facilities, and home infusion vendors. • Assess appropriate site of care utilization and continued medical necessity reviews for prior authorization to vendors. • Ensure communication with MD offices in relation to Site of Care program. • Track and contact MD identified as providing scope drug in setting that is at a higher level of care than necessary. • Assist transfer of members from higher level of care to Home / AIS setting for optimal outcomes. • Create a Medical Drug dashboard reporting the status of volumes and costs. • Identify and implement cost saving strategies by shifting the patient site of service. • Develop, facilitate, and communicate discharge plans in partnership with the member, physician and vendor and at times concurrent review team, case management if applicable, social workers. • Coordinate services from one setting to another, acute setting to home/Ambulatory Infusion Suites throughout the continuum of care.

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