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Pediatric Care Management Registered Nurse
2 months ago
Pediatric Care Management Registered Nurse
Job Reference:
Category: Utilization Review and Case Management
Department: MHP CHILDREN'S PROGRAM
Job Type: Regular
Employment Type: Full-Time
Salary Range: $100, $105,646.00
MetroPlusHealth is dedicated to empowering communities by fostering connections through healthcare. We believe that access to health services is a fundamental right. If you possess empathy and a collaborative mindset, consider contributing to our mission. You can take pride in your daily contributions to the community.
About MetroPlusHealth
MetroPlusHealth delivers exceptional healthcare services to residents across various boroughs through a comprehensive array of programs, including New York State Medicaid Managed Care, Medicare, Child Health Plus, and more. As a proud subsidiary of NYC Health + Hospitals, the largest public health system in the nation, MetroPlusHealth collaborates with over 27,000 healthcare providers and specialists. For over three decades, we have been committed to nurturing strong relationships with our members and providers to support New Yorkers in achieving optimal health.
Position Overview
The Care Manager (CM) is tasked with evaluating and approving Care Plans, CANS-NY assessments, and Home and Community-Based Services (HCBS). The CM is also responsible for authorizing inpatient services and Durable Medical Equipment (DME) for medically fragile children in accordance with established guidelines. The CM collaborates with Health Home Coordinators and local agencies to ensure appropriate access, care levels, and continuity of services for medically fragile children.
Key Responsibilities
- Collaborate with Health Home Coordinators and local agency Care Managers to address comprehensive treatment needs of patients.
- Coordinate service requirements with community organizations.
- Provide education and support to families of members.
- Conduct quarterly follow-up assessments with Health Home Coordinators.
- Offer clinical guidance to assist members in reaching their health objectives.
- Maintain extensive knowledge of community resources and services.
- Prepare for and engage in clinical rounds.
- Work with physicians and clinical teams for discharge planning and necessary DME.
- Perform telephonic care reviews and authorization assessments for pre-admission and ongoing care.
- Determine appropriate levels of care.
- Consult with Clinical Peer Reviewers regarding service requests that do not meet medical necessity criteria.
- Engage with Clinical Peer Reviewers to discuss clinical questions and alternative treatment options.
- Provide information to families, Health Home coordinators, and clinical providers regarding medical benefits.
- Offer telephone triage and crisis intervention as needed, ensuring members have access to local services.
- Identify quality of care issues and report them through appropriate channels.
- Perform additional duties as assigned by leadership.
Minimum Qualifications
- Bachelor's Degree required.
- A minimum of two years of clinical experience in an acute care environment.
- Experience with Interqual Guidelines is required.
- Knowledge of medical care and HCBS services for medically fragile children is essential.
Licensure and Certification Requirements
- A valid New York State RN license.
- Professional competencies including integrity, customer focus, and effective communication skills.
- Clinical expertise and subject matter knowledge.
- Ability to learn and master UM/CM systems and procedures.
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