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 joining us. You can take pride in your contributions every day.
About NYC Health + Hospitals
MetroPlusHealth delivers top-tier healthcare services to residents across the Bronx, Brooklyn, Manhattan, Queens, and Staten Island through a wide array of offerings, including New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, and more. As a wholly owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth collaborates with over 27,000 primary care providers, specialists, and clinics. For over three decades, MetroPlusHealth has focused on cultivating strong relationships with its members and providers to support New Yorkers in achieving their healthiest lives.
Position Overview
The Care Manager (CM) is tasked with evaluating 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 in accordance with UM requirements established by the Office of Health Insurance Programs for Medically Fragile Children. The CM collaborates with Health Home Coordinators and LDSS/VCFA to ensure appropriate access, care levels, needs assessment, and continuity of care for Medically Fragile and Care at Home children.
Key Responsibilities
- Facilitates coordination with Health Home Coordinators and LDSS/VFCA Care Managers to ensure comprehensive treatment needs are met.
- Links members' service requirements with community organizations.
- Provides education and support to members' families.
- Conducts quarterly follow-up assessment calls to Health Home Coordinators.
- Offers clinical guidance and support to help members achieve their health goals.
- Possesses extensive knowledge of community resources and services.
- Prepares for and engages in all clinical rounds.
- Collaborates with physicians and other members of the Providers' Clinical Teams for discharge planning and necessary DME.
- Performs telephonic care reviews and authorization determinations for pre-admission and ongoing care with hospitals, clinics, and home services.
- Assesses appropriate levels of care.
- Consults with Clinical Peer Reviewers when service requests do not meet medical necessity criteria.
- Engages with Clinical Peer Reviewers to discuss clinical and authorization inquiries, alternative treatment options, and specific case concerns.
- Provides information to members' families, Health Home coordinators, LDSS/VFCA, clinical, and HCBS providers regarding medical benefits.
- Delivers telephone triage and crisis intervention to callers, ensuring members have access to local services and resources when necessary.
- Identifies quality of care issues and reports them through internal and external channels.
- Performs additional duties as assigned by the Medical Director, Director of Children's Special Services, Senior Director of Children's Special Services, and 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 for medically fragile children is necessary.
- A valid NYS RN license.
- Professional Competencies include:
- Integrity and Trust.
- Customer Focus.
- Functional/Technical skills.
- Effective Written and Oral Communication.
- Clinical skills and subject matter expertise.
- Ability to learn and master UM/CM MetroPlusHealth systems and procedures.
- Customer Service skills.
- Strong oral and written communication abilities.
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