Job Description

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visitemblemhealth.com . If you’rean EmblemHealth employee, unlock your career potential by signing in at the top of this page. Access your employee profile to view internal job postings and explore new opportunities. Assess medical risk for each identified claimant utilizing all available information and applying appropriate guidelines to meet the financial risk management goals of the company. Review detailed large claim reports and available clinical information from a variety of sources including trigger reports, detailed individual claim reports, pending and denied reports, case management reports, and utilization reports. Present and document a clear medical review summary with an analysis of the current clinical conditions and a future annual claim projection to underwriting team. Provide services per the NYCE contract. Principal Accountabilities Research rare/complicated medical conditions/treatment options using resources including the internet, nursing, clinical resource tools by state/network. Ensure timely and accurate communications of medical necessity review results to the original requester (e.g., primary care team, specialty providers, vendors) in compliance with regulatory and contractual requirements. Analyze medical procedures codes, medication J codes, and prescription drug reports to assist in predicting the future claim costs and clinical prognosis utilization needs. Make recommendations based on medical review summary; conduct necessary referrals to Clinical Cost Containment Services; partner with team(s) as needed to ensure care plan and approach are effective to support financial risk management and clinical cost containment based on the identified clinical needs and predicted prognosis. Provide clinical opinion from knowledge, experience and/or research to claims examiners and underwriters as requested or deemed appropriate. Consult with internal and external clients on high cost claims and successfully engage effective clinical risk management strategies. Plan and develop work plans, establish timelines, and set goals for assigned work. Utilize a comprehensive approach to risk mitigation within area of responsibility by monitoring regulatory changes to ensure on-going adherence to reporting requirements. Stay informed of current medical and drug trends and share information with team members. Qualifications Education, Training, Licenses, Certifications Bachelor’s degree preferred. Years of experience can be substituted for years generally required for a degree. Active, unrestricted Nursing License (RN or LPN) required. Relevant Work Experience, Knowledge, Skills, and Abilities 4 – 6+ years of professional relevant work experience. 4 years’ experience in medical underwriting or medical risk management, clinical coding or AHIP certification. Three years’ direct clinical experience, preferably in an acute care. Additional years of experience/specialized training may be considered in lieu of educational requirements. Ability to successfully work independently; organizational skills; ability to manage multiple tasks simultaneously. Demonstrated analytical skills; ability to exercise sound judgment, initiative and discretion. Proficient with MS Office (Word, Excel, Powerpoint, Outlook). Demonstrated ability to establish effective working relationships with coworkers and customers. Knowledge of ICD 10 coding and medical terminology. Knowledge of state and federal regulations related to underwriting. Strong verbal, written, interpersonal communication and customer service skills. Ability to interpret policies and procedures and communicate complex clinical topics effectively. Additional Information Requisition ID: 1000002691 Hiring Range: $68,040-$118,800 Security Disclosure If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail. Pay Disclosure At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation. EEOC Statement We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law. Sponsorship Statement At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs. #J-18808-Ljbffr EmblemHealth

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