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Care Manager (RN) (Medicaid)
MetroPlus Health Plan New York, NY Full-Time
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’s 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 primary goal of the Care Manager is to optimize members’ health care and delivery of care experience with expected cost savings due to improved quality of care. This is accomplished through engagement and understanding of the member’s needs, environment, providers, support system and optimization of services available to them. Care Manager is expected to assess and evaluate member’s needs, be a creative, efficient and resourceful problem solver. In collaboration with the members’ care team, a plan of care with individualized goals and interventions is developed, implemented and outcomes evaluated.
Job Description
- Address member’s problems and needs: clinical, psychosocial, financial, environmental
- Provide services to members of varying age, risk level, clinical scenario, culture, financial means, social support, and motivation
- Engage members in a collaborative relationship, empowering them to self-manage their physical, psychosocial and environmental health to improve and maintain lifelong well being
- Prepare member-oriented plan of care with member, caregivers, and health care providers, integrating concepts of cultural sensitivity and privacy practices
- Participate in interdisciplinary rounds
- Ensure plans of care have individualized goals and interventions
- Communicate plan of care to Primary Care Physician
- Address gaps in care with the member and provider
- Address members social determinants of health issues
- Link members to available resources
- Provide care management support during Transitions of Care
- Ensure member/caregiver understanding as it relates to language barriers, stress reaction or cognitive limitations/barriers
- Train member on relevant chronic diseases, preventive care, medication management (medication reconciliation and adherence), home safety, etc.
- Provide Complex care management including but not limited to; ensuring access to care, reducing unnecessary hospitalizations, and appropriately referring to community supports
- Advocate for members by assisting them to address challenges and make informed choices regarding clinical status and treatment options
- Employ critical thinking and judgment when dealing with unplanned issues
- Maintain knowledge of Chronic Conditions and use job aids as a guidance
- Maintain accurate, comprehensive and current clinical and non-clinical documentation in DCMS, the Care Management System
- Comply with all orientation requirements, annual and other mandatory trainings, organizational and departmental policies and procedures, and actively participate in evaluation process
- Maintain professional competencies as a Care Manager
- Other duties as assigned by Manager
Minimum Qualifications
- Background: Registered Nurse, Bachelor’s Degree in Nursing required
- An equivalent combination of training, educational background, and experience in related fields such as hospital, home care, ambulatory setting and educational disciplines. Prior experience in Care Management in a health care and/or Managed Care setting preferred
- Proficiency with computers navigating in multiple systems and web- based applications
- Confident, autonomous, solution driven, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient and proactive
- Strong verbal and written communication skills including motivational coaching, influencing and negotiation abilities
- Time management and organizational skills
- Strong problem-solving skills
- Ability to prioritize and manage changing priorities under pressure
- Must know how to use Microsoft Office applications including Word, Excel, and PowerPoint and Outlook.
- Ability to proficiently read and interpret medical records, claims data, pharmacy, lab reports and prescriptions required
- If needed, ability to travel within the MetroPlus service area to participate in facility visits, community events, home visits or other community meetings, including conferences.
- Registered Nurse or LMSW/LCSW with current NYS license
Professional Competencies:
- Integrity and Trust
- Customer Focus
- Functional/Technical Skills
- Written/Oral Communications
Recommended Skills
- Attention To Detail
- Certified Nurse Practitioner
- Claim Processing
- Clinical Works
- Coaching And Mentoring
- Communication