CARE MANAGEMENT ANALYST CMO

Montefiore Health System•Norfolk, VA

12d•$56,000 - $70,000•Onsite

About The Position

Under the supervision of a licensed or certified clinical professional, the Care Management Analyst (CMA) is responsible for supporting the operational functions of care management programs, including complex care, chronic care, palliative care, and care transitions. The Care Management Analyst coordinates and manages key care management processes to ensure members receive timely, appropriate, and cost-effective healthcare services while adhering to organizational policies, regulatory requirements, and payer guidelines. The CMA gathers, reviews, and organizes information from multiple sources, including members, caregivers, physicians, clinical information systems, and electronic health records (EHRs). Using established protocols, the CMA evaluates information related to utilization and benefit application, facilitates care coordination activities, and escalates cases requiring clinical intervention to the appropriate care management staff. A primary responsibility of this role is managing medication prior authorizations through Pharmacy Benefit Managers (PBMs), ensuring timely access to prescribed therapies while meeting payer requirements.

Requirements

High School Diploma or GED required.
Current LPN licensure and registration in NY State required.
Proficiency in Microsoft Office Suite (Word, Excel, Outlook)
Experience with case management and utilization management software
Strong data entry and keyboarding skills
Familiarity with electronic health records (EHRs)
Experience using electronic fax systems and automated call distribution systems
Ability to navigate web-based healthcare applications and databases
Experience operating standard office equipment, including scanners and copiers
Strong analytical and critical thinking skills
Excellent organizational and time management abilities
Effective written and verbal communication skills
Ability to prioritize multiple assignments in a fast-paced environment
Strong customer service and interpersonal skills
Ability to maintain confidentiality and exercise sound judgment
Ability to work collaboratively with interdisciplinary teams while managing multiple priorities

Nice To Haves

Bachelor’s or master’s degree preferred (Nursing, Healthcare Administration, Public Health, or another health or human services fields)
Experience processing medication prior authorizations with Pharmacy Benefit Managers (PBMs), health plans, or specialty pharmacies strongly preferred.
Experience in medical management within a managed healthcare environment preferred.
Previous case management, utilization management, care coordination, or population health experience preferred.
Experience working with electronic health records (EHRs) and clinical documentation systems preferred.

Responsibilities

Coordinate operational activities supporting complex care, chronic care, palliative care, and care transitions programs.
Process and manage medication prior authorizations through Pharmacy Benefit Managers (PBMs), health plans, and specialty pharmacies.
Collect, review, and organize clinical and administrative information from members, caregivers, providers, and electronic health records.
Evaluate benefit eligibility and utilization information in accordance with established policies, procedures, and clinical guidelines.
Manage assigned care management processes and/or a designated caseload while ensuring timely follow-up and documentation.
Collaborate with interdisciplinary care management teams to facilitate appropriate interventions and continuity of care.
Serve as a resource to team members, physicians, providers, members, caregivers, and internal departments regarding care management processes.
Maintain accurate documentation within care management and utilization management systems.
Ensure compliance with organizational, regulatory, and payer requirements while maintaining confidentiality of member information.
Support quality improvement initiatives and other departmental operational activities as assigned.