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 interview 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 Care Management team, develops 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 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 request for additional services based on assessments and using evidence-based standards refer denial, reduction, or limitation of service request to Medical Director.
• Assist members with the coordination of services both within and outside networks as appropriate. Includes facilitating discharge from acute setting and alternate settings.
• Provides Care Coordination through continuum of care.
• Optimizes both the quality of care and the quality of life for the MetroPlusHealth members.
• Provides Care Coordination through continuum of care.
• Optimizes both the quality of care and the quality of life for the MetroPlusHealth members.
• Coordinate with Utilization Management (UM) department on concurrent and retrospective review.
• Follow up with assigned nurses for clinical updates to care plan.
• Document within two business day's coordination notes and routine contacts with the members according to the level of risk assigned to them.
• Participate in team care planning meetings.
• Handles complains that can be resolved in one day
• Assists Customer Service and the UM department by providing records and materials needed for grievances from MLTC/MAP program members
• Speaks to members who are delinquent in their spend-down payments.
• Cooperates with all department within MetroPlusHealth
• Identifies members appropriate for specialty programs.
• Performs all MLTC/MAP management activities in compliance with all regulatory agency requirements.
• Provides information on all requests from Quality Management Department to be reviewed by the various Quality committees.
• Completes all other tasks assigned by MLTC Dept. Leadership.
• Participates in the department on call schedule/being on call, which is rotated amongst the care team.

Minimum Requirements

• Bachelor's Degree required; BSN preferred.
• Two (2) to three (3) years clinical experience in certified home health agency (CHHA), Lombardi program and/or MLTC or MAP program
• Active New York State License as Registered Nurse

Professional Competencies

• Integrity and Trust
• Customer Service Focus
• Functional/Technical skills
• Written/Oral Communications