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Pediatric Care Management Registered Nurse
2 months ago
Pediatric Care Management Registered Nurse
Job Ref:
Category: Utilization Review and Case Management
Department: MHP CHILDREN'S PROGRAM
Location: New York, NY
Job Type: Regular
Employment Type: Full-Time
Salary Range: $100,000 - $105,646.00
MetroPlusHealth is dedicated to empowering New Yorkers by uniting communities through comprehensive care. We believe that healthcare is a right, not a privilege. If you possess compassion and a collaborative spirit, we invite you to work with us and take pride in your contributions every day.
About MetroPlusHealth
MetroPlusHealth delivers high-quality healthcare services to residents across various boroughs through a wide array of products, including New York State Medicaid Managed Care, Medicare, Child Health Plus, and more. As a 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 30 years, we have been committed to fostering strong relationships with our members and providers to support New Yorkers in achieving their healthiest lives.
Position Overview
The Care Manager (CM) plays a crucial role in 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 home care children, adhering to UM requirements established by the relevant health programs. The CM collaborates with Health Home Coordinators and LDSS/VCFA to ensure appropriate access, care levels, and continuity for medically fragile and home care children.
Key Responsibilities
- Coordinate with Health Home Coordinators and LDSS/VFCA Care Managers to meet comprehensive treatment needs of patients.
- Align member service needs with community resources.
- Educate and coach family members of patients.
- Conduct quarterly follow-up assessment calls with Health Home Coordinators.
- Provide clinical guidance and support to help members achieve their health goals.
- Maintain extensive knowledge of community resources and services.
- Prepare for and participate in clinical rounds.
- Collaborate with physicians and clinical teams for discharge planning and necessary DME.
- Perform telephonic care reviews and authorization determinations for pre-admission and ongoing care.
- Assess appropriate levels of care.
- Consult with Clinical Peer Reviewers for service requests that do not meet medical necessity criteria.
- Engage with Clinical Peer Reviewers to discuss clinical and authorization inquiries, alternative treatment options, and case-specific concerns.
- Provide information to families, Health Home coordinators, LDSS/VFCA, and clinical providers regarding medical benefits.
- Offer telephone triage and crisis intervention, ensuring members have access to local services and resources.
- Identify quality of care issues and report them through appropriate channels.
- Perform additional duties as assigned by supervisory personnel.
Minimum Qualifications
- 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.
Licensure and Certification Requirements
- A valid NYS RN license.
- Demonstrated professional competencies including integrity, customer focus, and effective communication skills.
- Ability to learn and master UM/CM MetroPlusHealth systems and procedures.
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