Care Transition Manager RN
4 weeks ago
MetroPlusHealth is 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, work with us. You can come to work being proud of what you do every day.
About NYC Health + Hospitals
MetroPlusHealth's provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens, and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists, and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
Job Overview
The primary goal of the Transitions of Care (TOC) Care Manager is to provide care coordination services as members move from one setting to another. Examples of these settings include inpatient facilities, emergency department, rehabilitation facilities, long-term care facilities, and certified home health agencies. The goal is to prevent re-admissions and reduce avoidable admissions. This is accomplished through engagement and understanding of members' needs, environment, providers, support system, and optimization of services available to them. In addition, ensuring follow-up appointments are scheduled, conducting medication reconciliation, and providing education related to members' condition and necessary steps to remain safely in the community. The TOC Care Manager is expected to assess and evaluate member needs, be a creative, efficient, and resourceful problem solver. In collaboration with the members' care team, a plan of care with individualized goals and interventions is 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 members' 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 team, 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.
- Address members' social determinants of health issues.
- Link members to available resources.
- Educate members and/or caregivers on relevant chronic diseases, preventive care, medication management (medication reconciliation and adherence), 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 a 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 evaluation processes.
- Maintain professional competencies as a care manager.
- Other duties as assigned by Leadership.
- 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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