Senior Care Specialist - Emblem Health
New York, NY 10001
About the Job
• Responsible for the execution of the non-clinical aspects of the Care Management process: ensure that information is
appropriately documented in the system to effectively execute member care plans; originate authorizations, assist with
escalated issues, request clinical information, perform case research as necessary, and essentially execute and coach all desk
level procedures of the programmatic function.
• Work seamlessly with the interdisciplinary team to ensure everything that a member need is addressed.
• Provide confidential administrative support and assistance to the department and support the department in all aspects of
daily project operations
• Serve as the subject matter expert amongst the group; handle escalated cases.
• Provide confidential and potentially complex administrative support and assistance to the department in all aspects of daily
program operations.
• Provide telephonic outreach to members that have been identified for care management and ensure members' needs are
supported throughout the duration of member enrollment to the program, coordination of referrals to homecare providers
for members receiving services, coordinating with Care Manager on members' care plan, making appropriate referrals to the
interdisciplinary care team, coordinating post-acute services on behalf of members, assisting with community resource needs
and more.
• Support the Care Specialists and team members in working with reports and guide Care Specialists when needed.
Principal Accountabilities
• Care management team support. Document, organize and create cases based on intake.
• Ensure execution of escalated cases; troubleshoot issues.
• Prioritize and present escalated issues to Supervisor.
• Work collaboratively, as a critical component of the Medical Management team, to facilitate all clerical and
administrative processes and activities.
• Perform accurate and timely intake and data entry for all Care Management requests and referrals for all lines of
business, upon receipt of inbound requests, via call, fax and web portal, in accordance with departmental policy and
regulatory requirements.
• Perform member telephonic outreach for program enrollment with the goal of retaining members in the Care
Management Program.
• Triage cases and assign receipts to appropriate teams.
• Communicate and/or respond to inquiries from providers, facilities and members.
• Initiate completion of member and provider correspondence and verbal outreach according to departmental
guidelines.
• Enter and maintain documentation in electronic record, meeting defined timeframes and performance standards.
• Provide phone queue management for both incoming and outgoing calls.
• Address customer experience: provide research and issue resolution as necessary; ensure participant or providers'
inquiries and questions are answered.
• Perform research activities to identify members with gaps in care and those who could benefit from targeted Care
Management Service.
• Under the direction of a Care Manager, manage caseload and update care plans for low and moderate risk members
in collaboration with the clinical team.
• Support care interventions including making doctor's appointments, health coaching, referrals to internal and
external resources, assist with transportation issues.
• Leverage motivational interviewing skills and a member-centric approach to identify members' needs, prioritize and
support care plan.
• Perform a wide range of research and educational outreach activities to encourage healthy behaviors, such as
outreaching to identified members who need a primary care provider or who may have gaps in care related to
recommended tests or provider visits and facilitate gap closure and receipt of evidence-based care.
• Participate in project tracking and program development.
• Adhere to processes for collecting member-specific clinical and demographic data from providers and other entities
as required by clinical staff.
• Support communication and coordination with delegated entities, as necessary.
• Create, interpret, review, edit and organize departmental and company audits and reports.
• Identify and communicate relevant documents to the appropriate department(s), external providers and vendors.
• Review documents for accuracy, completeness and timeliness for submission to the appropriate leadership teams.
• Assist in the coordination of special projects.
• Coordinate directly with community-based organizations and agencies to identify available and/or alternative
resources for a wide range of concerns, including home safety, financial assistance, caregiver support and transition
assistance.
• Serve as Subject Matter Experts for Medical Management Operations team integration and adherence.
• Actively participate in assigned committees and projects.
• Provide coverage, support and complete administrative duties for the department.
Education, Training, Licenses, Certifications
• High School Diploma required.
• Associate Degree or Medical Assistant certification preferred.
• Bachelor's in related field preferred.
Relevant Work Experience, Knowledge, Skills, and Abilities
• Minimum 2 - 3 years' experience in health care and/or regulatory related environment (R)
• Additional years of experience/certifications/training may be considered in lieu of educational requirements.
• Requires coverage during weekends and holidays as needed.
• PC proficiency: accurate data entry/typing; word processing; database/spreadsheet; presentation; e-mail. (R)
• Administration and organizational skills (R)
• Ability to perform independently and prioritize projects and assignments (R)
• Ability to exercise discretion in relationships with internal and external contacts; and to understand and adhere to
confidentiality and proprietary requirements. (R)
• Understanding of and sensitivity to cultural differences and needs of community members. (R)
Additional Information
- Requisition ID: 1000000636
- Hiring Range: $26.44-$31.25 per hour