Insurance Utilization Review Jobs in Rochester, NY

Description

We provide high quality services from skilled nursing and restorative care to housing, assisted living and community-based wellness programs. We are committed to meeting each individual’s needs, in a culturally competent manner, supporting family and loved ones through transitions, and fulfilling our pledge…Life. Inspired Every Day.

Starting Salary: $85,000/annually

• Your Health & Well-being: We take care of you. We offer 100% employer-paid medical insurance for High-Deductible Health Plan (HDHP) for single-subscribers.
• We also offer Health Saving Accounts (HSA) with Weekly Employer Contributions. Alternatively, we also offer Flexible Spending Accounts (FSA).
• Additionally, staff are eligible for dental insurance with orthodontist coverage.
• 401(K) with Company Match: 100% company match on the first 3% of your contributions.
• Competitive Pay Rates: We offer competitive rates that reflect your skills and experience. ESLC processes payroll on a weekly basis.
• Tuition Assistance: Our tuition assistance program provides financial support for courses and degrees that will help you grow professionally with us.
• ETO (Earned Time Off): Generous ETO plan that accrues on a weekly basis for use after 90 days of employment.
• Paid Holidays: ESLC has six designated holidays and one floating holiday.

The Director of Community Dementia Services provides operational leadership to the Community Dementia Services program, ensuring consistent implementation, high-quality services, staff support, caregiver engagement, partner coordination and measurable outcomes. This role converts approved dementia program priorities into effective workflows, staffing practices, training, reporting processes and community-based services for people living with dementia and their caregivers.

• Provide operational leadership for ESLC’s Community Dementia Services portfolio overseeing implementation and day-to-day performance across GUIDE care navigation, caregiver support, respite coordination, dementia-friendly programming, specialized IDD dementia supports, community education and training.
• Translate organizational priorities into operational workplans, timelines, workflows, staffing practices, training plans and measurable goals that support consistent, effective service delivery.
• Monitor service quality, participant and caregiver experience, referral and enrollment activity, partner engagement and staff accountability to ensure programs remain responsive, sustainable and effective.
• Provide financial oversight by monitoring program expenses, supporting budget planning and ensuring responsible stewardship of grant, payer and organizational funds.
• Identify operational barriers, emerging service needs and opportunities for improvement and provide recommendations to support planning, program refinement and future growth.
• Coordinate Community Dementia Services as an integrated service line by aligning GUIDE Model delivery domains, value based programs and other dementia-friendly home and community based services.
• Implement and strengthen GUIDE Model operations by maintaining effective workflows for referrals, eligibility, enrollment, assessments, care planning, caregiver support, respite services, 24/7 support, documentation, partner coordination and follow-up.
• Support quality improvement efforts by identifying workflow challenges, analyzing data trends, gathering staff, participant and caregiver feedback, testing improvements and escalating issues that affect program scope.
• Represent ESLC in community and partner settings with families, referral sources, clinical partners, community organizations, respite providers, payers and funders to strengthen relationships, increase referrals and enhance program visibility.
• Conduct referral-generating outreach with community, clinical and partner organizations.

• Review documentation and service records for completeness, timeliness, HIPAA compliance, billing readiness, payer requirements, funder reporting and audit preparedness.
• Track program metrics and prepare routine reports related to referrals, enrollment, caregiver contacts, respite utilization, education activities, satisfaction feedback and outcomes.
• Support quality improvement by identifying workflow challenges, reviewing data trends, gathering feedback and recommending improvements.
• Contribute to value-based and grant-funded program requirements by supporting outcome tracking, reporting, implementation updates and sustainability planning.
• Maintain compliance readiness through standard workflows, documentation practices, privacy safeguards, reporting processes and continuous quality improvement.
• Supervise and support assigned Dementia Services staff by fostering role clarity, accountability, collaboration, onboarding, training, performance expectations and regular check-ins aligned with program, payer, funder and ESLC requirements.

Requirements

• Bachelor’s degree in social work, public health, health administration, community health, gerontology, nursing, human services, or a related field required; Master’s degree preferred.
• Current valid New York State driver’s license and ability to travel to ESLC sites, community locations, partner organizations, and other locations as needed.
• Minimum of five to seven years of progressively responsible experience required in aging services, dementia care, community-based services, care navigation, caregiver support, healthcare-community partnerships, or related human services.
• Minimum of five to seven years of management experience required including staff supervision, program implementation, performance management, cross-functional coordination, partnership support and accountability for measurable outcomes.
• Demonstrated knowledge of Alzheimer’s disease and related dementias, including dementia progression, caregiver needs, family systems, dementia-friendly communication, care navigation, caregiver education, respite and home and community-based supports.
• Experience with Medicare GUIDE, value-based care, payer-supported service models, healthcare-community partnerships, clinical-community integration or similar care coordination models preferred.
• Proficiency in Microsoft Office (Word, Excel, PowerPoint) required.
• Experience developing and facilitating training materials for caregivers, staff, volunteers and community partners preferred.
• Demonstrated ability to implement program plans, manage workflows, support staff accountability, use data to monitor performance and communicate clearly with internal and external partners.
• Knowledge of documentation, privacy, quality assurance, compliance, billing readiness, payer reporting, funder reporting and audit-readiness expectations in healthcare-adjacent, value-based, reimbursable or grant-funded service environments preferred.
• Ability to contribute to grant applications, funder updates, payer reporting and sustainability planning by providing program information, outcomes, service data and implementation insight.
• Excellent written, verbal, curriculum development, training facilitation and presentation communication skills, with the ability to represent ESLC professionally and confidently with families, staff, community partners, referral sources, payers, funders and other external stakeholders; write, adapt and deliver clear dementia-related curriculum, reports, program updates, training content, presentations and communications that reflect the organization’s mission, values and standards.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Performing duties of this job requires occasional walking and standing in and around the residences and the community. Must be able to occasionally lift loads of 30 pounds without assistance and the ability to sit, talk, and hear is required. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, color vision, and the ability to adjust focus.

Episcopal SeniorLife Communities is an Equal Opportunity Employer.