Remote RN, LTSS Enrollment – New York
- Clinical License RN
- State(s) NY
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.
- 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.
Education, Training, Licenses, Certifications
- Bachelor’s degree
- RN required, with current active RN license
- CCM certification preferred
Relevant Work Experience, Knowledge, Skills, and Abilities
- 4 – 6+ years of clinical experience. (R)
- 5+ years of experience in care/case management, population health management, utilization review, quality assurance, or discharge planning (preferably within a managed care, home care, or community health organization. (R)
- Experience in case management/care coordination, managed care, and/or utilization management. (R)
- Additional experience/specialized training may be considered in lieu of Bachelor’s degree. (R)
- Experience with NYSDOH Medicaid program requirements and benefits under Long Term Care Proficiency in utilizing and analyzing UAS-NY assessments and assessment outcomes. (R)
- Organization/prioritization ability; and the ability to effectively manage a caseload of highly complex members. (R)
- Experience with Long-term Services and Supports (LTSS), Managed Long Term Care (MLTC). (R)
- Strong communication skills (verbal, written, presentation, interpersonal). (R)
- Computer proficiency: MS Office (Word, Excel, Powerpoint, Outlook); mobile technology (wireless phone/laptop, etc.). (R)
- System user experience in a highly automated environment. (R)
- Bilingual ability (verbal, written). (P)
- Strong cross-group collaboration, teamwork, problem solving, and decision-making skills. (R)
- Ability to work a flexible schedule (evenings, weekends and holidays) to meet member and/or caregiver and departmental scheduling needs. (R)