Case Manager, Maternity (RN or LMSW) – Excellus BCBS
Job Description
Conduct case management program activities in accordance with departmental, corporate, NYS Department of Health (DOH), Centers for Medicaid & Medicare Services (CMS), Federal Employee Program (FEP) and National Committee for Quality Assurance (NCQA) accreditation standards. Use a systematic approach to identify members meeting program criteria; assess opportunities to educate, support, coach, coordinate care and review treatment options through collaboration with providers and community-based resources.
Participate in a cross-functional, multi-disciplinary team to develop member-centric interventions and comprehensive care plans, identifying strategic interventions to address member needs, health goals and mitigate health‑care cost drivers.
Essential Accountabilities
Handle physical health member clinical management programs.
Maintain knowledge of current CMSA and NCQA Standards, and perform activities as directed by departmental policy and leadership, and state/federal regulations.
Carry out responsibilities in accordance with all regulatory and licensing requirements.
Maintain confidentiality and information‑management procedures per corporate policy.
Implement the case‑management process: identification, opening, assessment, education, care plans, member‑centric interventions, outcome measurement, closure and review.
Screen members, apply case‑management criteria and professional judgment to determine appropriateness for services.
Initiate case management, open cases timely and effectively, use motivational interviewing to ensure members understand essential information.
Collaborate with physicians and other providers to assess needs, develop interdisciplinary care plans, coordinate services, evaluate effectiveness and modify plans.
Assess member/caregiver knowledge of illness and initiate appropriate education interventions.
Collaborate with member/caregiver to set objectives, goals, and actions addressing barriers.
Provide resources and assistance to manage health across the continuum of care; act as liaison to providers and community resources.
Participate in inter‑disciplinary coordination and collaboration to ensure consistent, quality health‑care services.
Accept responsibility for continuing education and meet or exceed minimum continuing‑education requirements.
Promote health‑plan programs such as preventive health, web‑based self‑management tools and digital health applications.
Work collaboratively with all Case Managers to ensure continuity and coordination of care.
Assist with value‑based payment programs such as ACQA.
Demonstrate integrity and support Lifetime Healthcare Companies’ mission and values.
Maintain high regard for member privacy in accordance with corporate privacy policies.
Possibly participate in orientation of new staff.
Maintain regular, reliable attendance.
Perform other functions as assigned.
Level II (In Addition To Level I)
Manage all member clinical condition management programs.
Offer process improvement suggestions and participate in solving complex issues.
Mentor junior staff and provide coaching.
Consistently meet or exceed all productivity and performance metrics.
Work independently to coordinate and collaborate with members and providers.
Manage more complex assignments and/or larger caseloads.
Display leadership skills and serve as a role model.
Participate in orientation of new staff.
Level III (In Addition To Level II)
Process Management and Documentation
Identify, recommend, and evaluate new processes to improve productivity and efficiencies.
Assist in updating departmental policies, procedures, and manuals.
Identify and develop performance‑improvement opportunities.
Serve as subject‑matter expert and provide support for escalated issues.
Mentor and provide guidance to daily activities of the Case Management Department.
Provide backup for the Supervisor/Manager when necessary, including:
Participate in orientation and training for all staff.
Act as liaison for activities generated by CAU, CS, SIU, PR, or Sales & Marketing.
Ensure all regulatory requirements are met (NYS DOH, CMS, NCQA, HEDIS); serve as internal auditor.
Responsible for all aspects of the Case Management department functions including quality, productivity, utilization performance, and educational needs.
Active NYS RN or Registered Dietician or Physical Therapist licensure required.
Minimum of 3 years of clinical experience; case‑management experience preferred.
Proficiency with Microsoft Office Suite.
Experience interpreting managed‑care benefit plans and strong knowledge of government program contracts preferred.
Strong written and verbal communication skills.
Ability to multitask and balance priorities.
Work independently on a daily basis.
Deliver efficient, effective, and seamless care to members.
For FEP incumbents, case‑management certification required within 3 years.
Level II Qualifications
Minimum of 2 years in a case‑management position.
Case‑management certification preferred.
Demonstrate ability to emulate management escalation when necessary.
Proficiency in all related technology and documentation requirements.
Consistently meet or exceed performance metrics.
Level III Qualifications
Minimum of 5 years in a current case‑management or similar subject‑matter‑expert role.
Case‑management certification required.
Broad understanding of multiple functional areas and supporting systems.
Expertise in handling complex assignments, challenging situations, and highly visible issues.
Ability to lead training of new staff.
Demonstrated presentation skills.
Physical Requirements
Ability to travel and work long hours on a computer.
May require flexible hours to meet member discussion needs.
Our Company Culture
Employees are united by Lifetime Way Values & Behaviors: compassion, pride, excellence, innovation and having fun. We aim to be an employer of choice by valuing an inclusive workforce, innovative thinking, employee development, and competitive compensation and benefits.
We aspire for our employees’ interests and values to reflect the communities we serve and strongly encourage all qualified individuals to apply.
Equal Opportunity Employer
Lifetime Healthcare Companies is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
Compensation Range(s)
Level I / E2: $60,410 - $96,081
Level II / E3: $60,410 - $106,929
Level III / E4: $65,346 - $117,622
Actual salary will vary based on budget, experience, knowledge, skill, and education. The posted salary range reflects one component of our total rewards package, which may include health/dental insurance, retirement plan, wellness program, paid time off, and paid holidays.
Remote work may be available on a case‑by‑case basis.