Care Manager
3 weeks ago
At MetroPlus Health Plan, we are committed to empowering New Yorkers by uniting communities through care. We believe that healthcare is a right, not a privilege. If you have compassion and a collaborative spirit, we invite you to join our team.
Job SummaryThe Care Manager will be responsible for managing both simple and complex medical cases to achieve high-quality patient care outcomes and minimize unnecessary medical expenses. This will be achieved through the coordination of services, both outpatient and inpatient, and evaluating alternative care plans.
Key Responsibilities- Perform care management, including hospital admission certification, continued stay review, discharge planning, outpatient, and ancillary services review, following established MetroPlus Health Plan Utilization Management policies, procedures, and protocols.
- Oversee the coordination and delivery of comprehensive, quality healthcare and services for all members requiring care management in a cost-effective manner.
- Interact and obtain relevant clinical information from members' PCP and other providers; approve care that meets established criteria; and refer all other cases to the MetroPlus Health Plan Physician Advisor/Medical Director.
- Identify utilization trends and potential member needs by means of generating reports of encounter data, pharmacy data review, and new member health assessment forms.
- Evaluate member needs for referred cases (from providers or member self-referred).
- Assist all departments with the resolution of members' problems related to utilization management issues.
- Perform all Utilization Management activities in compliance with all regulatory agency requirements.
- Conduct medical record reviews as appropriate to case management functions.
- Participate in Medical Management grand rounds with the Physician Advisor.
- High School Diploma or General Equivalency Diploma (GED) required.
- 2-5 years' clinical experience in an acute or applicable care setting.
- UM/UR experience in managed care or hospital setting required.
- New York State license as Registered Nurse, License Practical Nurse, or Physical Therapist required.
We offer a competitive salary and a comprehensive benefits package. If you are passionate about delivering high-quality patient care and have a collaborative spirit, we encourage you to apply for this exciting opportunity.
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