Care Manager - ED

Job Description

Job Description

Duties:
The Care Manager develops, facilitates, monitors, and communicates a care plan in partnership with the member, their family or significant other, primary caregiver, the primary and/or the attending physicians, and various providers. Using the assessments and interview done by the Assessment Nurse, the Care Manager identifies the risk factors, strengths, challenges, and service needs of the member as they strive to keep them safe and well in their community setting.
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 be able to contact and discuss the care of the member with them.
Review assessment findings with the PCP to identify any concerns that have not been identified by the clinical team.
Identify the risk factors and assign the risk category to the member.
As part of Care Management team, develops a formal care plan for all services needed for the member, including the members disaster plan.
Monitor the condition of all members at least monthly, typically by telephone but via face-to-face when necessary.
Identify clinical issues that require immediate clinical assessment and/or treatment to reduce risk of unnecessary hospitalizations, ED visits or nursing home admissions.
Identify opportunities to improve the quality of care by ensuring members receive needed preventative and chronic disease care.
Prior approve request for additional services based on assessments and using evidence-based standards refer denial, reduction, or limitation of service request to Medical Director.
Assist members with the coordination of services both within and outside networks as appropriate. Includes facilitating discharge from acute setting and alternate settings.
Provides Care Coordination through continuum of care.
Optimizes both the quality of care and the quality of life for the MetroPlusHealth members.
Coordinate with Utilization Management (UM) department on concurrent and retrospective review.
Follow up with assigned nurses for clinical updates to care plan.
Document within two business days coordination notes and routine contacts with the members according to the level of risk assigned to them.
Participate in team care planning meetings.
Handles complains that can be resolved in one day
Assists Customer Service and the UM department by providing records and materials needed for grievances from MLTC/MAP program members
Speaks to members who are delinquent in their spend-down payments.
Cooperates with all department within MetroPlusHealth
Identifies members appropriate for specialty programs.
Performs all MLTC/MAP management activities in compliance with all regulatory agency requirements.
Provides information on all requests from Quality Management Department to be reviewed by the various Quality committees.
Completes all other tasks assigned by MLTC Dept. Leadership.
Participates in the department on call schedule/being on call, which is rotated amongst the care team.

Skills:
Five years minimum of clinical experience as a Registered Nurse. Leadership experience preferred. Experience with Care Coordination, Utilization review and discharge planning Computer literacy required.
Two (2) to three (3) years clinical experience in certified home health agency (CHHA), Lombardi program and/or MLTC or MAP program

Education:
RN Licensed as a Registered Nurse in the State of New York required.
Baccalaureate degree required.
PRI and Screen certification within three months of employment is required.
Master's Degree and Bilingual Spanish Certification in Case Management preferred.
RN Licensed as a Registered Nurse in the State of New York required.
Baccalaureate degree required.
PRI and Screen certification within three months of employment is required.
Masters Degree and Bilingual Spanish Certification in Case Management preferred.
Bachelors Degree required; BSN preferred.

Languages:
English