Pediatric Care Management Registered Nurse
4 weeks ago
MetroPlusHealth is dedicated to empowering New Yorkers by fostering community connections through healthcare. We believe that access to health services is a fundamental right. If you possess compassion and a collaborative mindset, consider contributing to our mission. You can take pride in your daily contributions to the well-being of others.
About NYC Health + Hospitals
MetroPlusHealth delivers high-quality healthcare solutions to residents across the Bronx, Brooklyn, Manhattan, Queens, and Staten Island through a diverse array of programs, including New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, and Essential Plan. As a wholly owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth boasts a network of over 27,000 primary care providers, specialists, and clinics. For over three decades, MetroPlusHealth has been devoted to cultivating strong relationships with its members and providers, enabling New Yorkers to lead their healthiest lives.
Position Overview
The Care Manager (CM) is tasked with reviewing and approving Plans of Care, CANS-NY assessments, and HCBS services. The CM is also responsible for authorizing inpatient and DME requests for Medically Fragile and Care at Home children, adhering to UM requirements established by the Office of Health Insurance Programs Principles for Medically Fragile Children. The CM collaborates with Health Home Coordinators and LDSS/VCFA to ensure appropriate access, level of care, and continuity of care for Medically Fragile and Care at Home children.
Key Responsibilities
- Collaborate with Health Home Coordinators and LDSS/VFCA Care Managers to ensure comprehensive treatment needs are addressed.
- Coordinate member service requirements with community organizations.
- Provide education and support to members' families.
- Conduct quarterly follow-up assessment calls to Health Home Coordinators.
- Offer clinical guidance and support to help members achieve their objectives.
- Maintain extensive knowledge of community resources and services.
- Prepare for and engage in all clinical rounds.
- Interact with physicians and other members of the Providers' Clinical Teams for discharge planning and necessary DME.
- Perform telephonic care reviews and authorization determinations for pre-admission and ongoing care with hospitals, clinics, and home services.
- Assess and determine the appropriate level of care.
- Consult with Clinical Peer Reviewers when service requests do not meet medical necessity criteria.
- Engage with Clinical Peer Reviewers to discuss clinical and authorization inquiries, alternative treatment options, and specific case concerns.
- Provide information to members' families, Health Home coordinators, LDSS/VFCA, clinical, and HCBS providers regarding medical benefits.
- Deliver telephone triage and crisis intervention to callers, ensuring members have access to local services and resources when necessary.
- Identify quality of care issues and report them through the appropriate internal and external channels.
- Perform additional duties as assigned by the Medical Director, Director of Children's Special Services, and the Senior Director of Children's Special Services.
- Bachelor's Degree required.
- A minimum of two years of clinical experience in an acute care environment.
- Experience with Interqual Guidelines is essential.
- Knowledge of medical care and HCBS services required for medically fragile children.
- A valid NYS RN license.
- Professional Competencies include Integrity and Trust, Customer Focus, Functional/Technical skills, and strong Written/Oral Communication abilities.
- Clinical skills and subject matter expertise are necessary.
- Ability to learn and master UM/CM MetroPlusHealth systems and procedures.
- Strong customer service orientation.
- Excellent oral and written communication skills.
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