Care Manager

About the role

MetroPlusHealth is a wholly-owned subsidiary of NYC Health + Hospitals, providing comprehensive healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens, and Staten Island. MetroPlusHealth's network includes over 27,000 primary care providers, specialists, and participating clinics.

Responsibilities

• Reviews and approves Plans of Care, CANS-NY assessments, and UM review for HCBS services.
• Care manages medically fragile children and supports coordination of services related to inpatient, homecare, specialty medications, and DME according to UM requirements.
• Coordinates with Health Home Coordinators and LDSS/VFCA Care Managers to ensure comprehensive treatment needs are met.
• Coordinates member’s service needs with community agencies.
• Provides education and coaching to members' family.
• Conducts follow-up quarterly assessment calls to Health Home Coordinators.
• Provides clinical guidance and support to assist members with achieving their goals.
• Has extensive knowledge of community resources/services.
• Prepares for and participates in all clinical rounds.
• Interacts with physicians and other members of the Providers’ Clinical Teams for discharge planning and required DME.
• Counsels with UM team to determine appropriate level of care.
• Consults with Clinical Peer Reviewers when requests for services do not meet medical necessity criteria.
• Interacts with Clinical Peer Reviewers to discuss clinical/authorization questions, alternative treatment options, and concerns regarding specific cases.
• Provides information to members' families, Health Home coordinators, LDSS/VFCA, clinical, and HCBS providers regarding medical benefits.
• Performs telephone triage and crisis intervention to callers and, when necessary, ensures members have access to local services and resources.
• Recognizes quality of care issues and reports them appropriately through internal and external processes.
• Performs other duties as assigned by Medical Director for Medically Fragile Children, Senior Director of Children’s Special Services, and the Director of Children’s Special Services.

Requirements

• A minimum of a Bachelor’s Degree required.
• Valid New York State license and current registration to practice as a Registered Professional Nurse (RN) issued by the New York State Education Department (NYSED).
• A minimum of two years’ clinical experience in an acute care setting.
• Experience using InterQual Guidelines required.
• Knowledge of medical care and HCBS services needed by medically fragile children.

Qualifications

• Must be able to learn and master UM/CM MetroPlusHealth systems and procedures.
• Must possess excellent clinical skills and subject matter knowledge.
• Must have strong customer service oral and written communication skills.