Care Manager RN Specialist
2 days ago
MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that health care is a right, not a privilege.
As a Transitions of Care (TOC) Care Manager, you will provide care coordination services as members move from one setting to another. Your goal will be to prevent re-admissions and reduce avoidable admissions by engaging with members, understanding their needs, environment, providers, support system, and optimizing available services.
About the Role
The primary responsibility of this position is to assess and evaluate member needs, providing creative, efficient, and resourceful solutions. In collaboration with the members' care team, a plan of care with individualized goals and interventions will be updated, implemented, and evaluated.
Key Responsibilities
- Provide care management support during transitions of care.
- Complete transitions of care assessments to identify member needs.
- Complete medication reconciliation.
- Address member's problems and needs: clinical, psychosocial, financial, environmental.
- Engage members in a collaborative relationship, empowering them to self-manage their physical, psychosocial, and environmental needs.
- Prepare member-oriented plans of care with members, caregivers, and members of their care teams, integrating concepts of cultural sensitivity and privacy practices.
- Ensure plans of care have individualized goals and interventions.
- Communicate plans of care with primary care physicians.
- Address gaps in care with members and providers.
- Link members to available resources.
- Educate members and/or caregivers on relevant chronic diseases, preventive care, medication management, home safety, etc.
- Ensure 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.
- Conduct follow-up calls as per transition of care protocols.
- Employ critical thinking and judgment when dealing with unplanned issues.
- Maintain knowledge of chronic conditions and use job aids as guidance.
- Ability to use data as a tool in tracking and trending outcomes and clinical information.
- Maintain accurate, comprehensive, and current clinical and non-clinical documentation in the care management system.
- Comply with all orientation requirements, annual, and other mandatory trainings, organizational, and departmental policies and procedures, and actively participate in the evaluation process.
- Maintain professional competencies as a care manager.
Requirements
- Bachelor's Degree required.
- Minimum 2 years of care management experience in a healthcare setting or in a managed care organization.
- Ability to proficiently read and interpret medical records, claims data, pharmacy, lab reports, and prescriptions required.
- Ability to work closely with members and caregivers.
- Ability to work collaboratively with various team members, interdepartmentally, and leadership.
- Registered Nurse with current NYS license.
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