Empower. Unite. Care.
MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.
About NYC Health + Hospitals
MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens, and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists, and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
Position Overview
The Care Manager develops, facilitates, monitors, and communicates a care plan in partnership with the member, his/her family or significant other, primary caregiver, the primary and/or the attending physicians, and various providers. Using the assessments and interviews done by the Assessment Nurse, the Care Manager identifies the risk factors, strengths, challenges, and service needs of the member as they strive to keep him/her safe and well in their community setting.
Job Description
- Review and evaluate the assessment and UAS information for members in the MLTC and MAP lines of business.
- Develop a working relationship with the PCP to be able to contact and discuss the care of the member with them.
- Review assessment findings with the PCP to identify any concerns that have not been identified by the clinical team.
- Identify the risk factors and assign the risk category to the member.
- As part of the Care Management team, develop a formal care plan for all services needed for the member, including the member’s disaster plan.
- Monitor the condition of all members at least monthly, typically by telephone but via face-to-face when necessary.
- Identify clinical issues that require immediate clinical assessment and/or treatment to reduce the risk of unnecessary hospitalizations, ED visits, or nursing home admissions.
- Identify opportunities to improve the quality of care by ensuring members receive needed preventative and chronic disease care.
- Prior approve requests for additional services based on assessments and using evidence-based standards; refer denial, reduction, or limitation of service requests to the Medical Director.
- Assist members with the coordination of services both within and outside networks as appropriate, including facilitating discharge from acute settings and alternate settings.
- Provide Care Coordination through the continuum of care.
- Optimize both the quality of care and the quality of life for the MetroPlusHealth members.
- Coordinate with the Utilization Management (UM) department on concurrent and retrospective review.
- Follow up with assigned nurses for clinical updates to the care plan.
- Document within two business days coordination notes and routine contacts with the members according to the level of risk assigned to them.
- Participate in team care planning meetings.
- Handle complaints that can be resolved in one day.
- Assist Customer Service and the UM department by providing records and materials needed for grievances from MLTC/MAP program members.
- Speak to members who are delinquent in their spend-down payments.
- Cooperate with all departments within MetroPlusHealth.
- Identify members appropriate for specialty programs.
- Perform all MLTC/MAP management activities in compliance with all regulatory agency requirements.
- Provide information on all requests from the Quality Management Department to be reviewed by the various Quality committees.
- Complete all other tasks assigned by MLTC Dept. Leadership.
- Participate in the department on-call schedule/being on call, which is rotated amongst the care team.
Minimum Qualifications
- Bachelor’s Degree required; BSN preferred.
- Two (2) to three (3) years clinical experience in a certified home health agency (CHHA), Lombardi program, and/or MLTC or MAP program.
- Active New York State License as a Registered Nurse.
Professional Competencies
- Integrity and Trust
- Customer Service Focus
- Functional/Technical skills
- Written/Oral Communications
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