CARE MANAGEMENT ANALYST CMO

Introduction To heal, to teach, to discover and to advance the health of the communities we serve. To learn more about the “Montefiore Difference” – who we are at Montefiore and all that we have to offer our associates, please click here. Overview 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 organisational 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 utilisation 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 authorisations through Pharmacy Benefit Managers (PBMs), ensuring timely access to prescribed therapies while meeting payer requirements. Responsibilities Coordinate operational activities supporting complex care, chronic care, palliative care, and care transitions programs. Process and manage medication prior authorisations through Pharmacy Benefit Managers (PBMs), health plans, and specialty pharmacies. Collect, review, and organise clinical and administrative information from members, caregivers, providers, and electronic health records. Evaluate benefit eligibility and utilisation 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 utilisation management systems. Ensure compliance with organisational, regulatory, and payer requirements while maintaining confidentiality of member information. Support quality improvement initiatives and other departmental operational activities as assigned. Requirements Education/Licensure: High School Diploma or GED required. Bachelor’s or Master’s degree preferred (Nursing, Healthcare Administration, Public Health, or another health or human services fields). Current LPN licensure and registration in NY State required. Experience: Experience processing medication prior authorisations 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, utilisation management, care coordination, or population health experience preferred. Experience working with electronic health records (EHRs) and clinical documentation systems preferred. Technical Skills: Proficiency in Microsoft Office Suite (Word, Excel, Outlook). Experience with case management and utilisation 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. Knowledge, Skills & Abilities: Strong analytical and critical thinking skills. Excellent organisational and time management abilities. Effective written and verbal communication skills. Ability to prioritise multiple assignments in a fast-paced environment. Strong customer service and interpersonal skills. Ability to maintain confidentiality and exercise sound judgement. Ability to work collaboratively with interdisciplinary teams while managing multiple priorities. #J-18808-Ljbffr Montefiore