Care Coordinator
2 weeks ago
MetroPlus Health Plan Inc is seeking a skilled Transitions of Care Manager RN to join our team. As a key member of our care management program, you will play a critical role in ensuring seamless transitions of care for our members.
Key Responsibilities- Provide care coordination support during transitions of care, ensuring a smooth transition from one healthcare setting to another.
- Conduct thorough assessments to identify member needs and develop individualized plans of care.
- Collaborate with members, caregivers, and healthcare providers to ensure effective communication and coordination of care.
- Address member problems and needs, including clinical, psychosocial, financial, and environmental concerns.
- Empower members to self-manage their physical, psychosocial, and environmental needs through education and support.
- Develop and implement plans of care that integrate concepts of cultural sensitivity and privacy practices.
- Communicate plans of care with primary care physicians and other healthcare providers.
- Identify and address gaps in care, ensuring members receive necessary services and support.
- Link members to available resources and services, including community-based programs and support groups.
- Provide education and support on relevant chronic diseases, preventive care, medication management, and home safety.
- Ensure access to care, reducing unnecessary hospitalizations and referrals to community supports.
- Advocate for members, assisting them to address challenges and make informed choices regarding clinical status and treatment options.
- 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 evaluation processes.
- 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.
- Integrity and Trust
- Customer Focus
- Functional/Technical skills
- Written/Oral Communication
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