RN Care Manager Managed Long Term Care

$105,646 - $105,646/Yr

Metroplus Health Plan - New York, NY

Full-time - Mid Level

New York, NY

Professional, Scientific, and Technical Services

About the position

The RN Care Manager for Managed Long Term Care at MetroPlusHealth is responsible for developing, facilitating, monitoring, and communicating care plans in collaboration with members, their families, and healthcare providers. This role focuses on identifying risk factors and service needs to ensure members receive appropriate care and support in their community settings, ultimately optimizing their quality of care and life.

Responsibilities

• Review and evaluate the assessment and UAS information for members in the MLTC and MAP lines of business.
• Develop a working relationship with the PCP to discuss the care of the member.
• Review assessment findings with the PCP to identify any concerns not identified by the clinical team.
• Identify risk factors and assign risk categories to members.
• Develop formal care plans for all services needed for members, including disaster plans.
• Monitor the condition of all members at least monthly, typically by telephone or face-to-face when necessary.
• Identify clinical issues requiring immediate assessment or treatment to reduce unnecessary hospitalizations, ED visits, or nursing home admissions.
• Ensure members receive needed preventative and chronic disease care to improve quality of care.
• Prior approve requests for additional services based on assessments and evidence-based standards; refer denials to the Medical Director.
• Assist members with coordination of services within and outside networks, including discharge facilitation from acute settings.
• Provide Care Coordination through the continuum of care.
• Coordinate with Utilization Management (UM) department on concurrent and retrospective reviews.
• Follow up with assigned nurses for clinical updates to care plans.
• Document coordination notes and routine contacts with members within two business days according to assigned risk levels.
• Participate in team care planning meetings.
• Handle complaints that can be resolved in one day.
• Assist Customer Service and UM department by providing necessary records for grievances from MLTC/MAP program members.
• Speak to members delinquent in their spend-down payments.
• Cooperate with all departments within MetroPlusHealth.
• Identify members appropriate for specialty programs.
• Perform all MLTC/MAP management activities in compliance with regulatory agency requirements.
• Provide information for Quality Management Department reviews by various Quality committees.
• Complete all other tasks assigned by MLTC Department Leadership.
• Participate in the department on-call schedule, which is rotated among the care team.

Requirements

• Bachelor's Degree required; BSN preferred.
• Two (2) to three (3) years clinical experience in certified home health agency (CHHA), Lombardi program, and/or MLTC or MAP program.
• Active New York State License as Registered Nurse.

Nice-to-haves

• Integrity and Trust
• Customer Service Focus
• Functional/Technical skills
• Written/Oral Communications

Benefits

• Competitive salary
• Comprehensive health insurance
• Retirement savings plan
• Paid time off
• Professional development opportunities