Care Manager, Registered Nurse (MLTC)
Company: MetroPlus Health Plan
Location: Jersey City
Posted on: January 15, 2022
About NYC Health + HospitalsMetroPlus Health Plan 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, MetroPlus ' network
includes over 27,000 primary care providers, specialists and
participating clinics. For more than 30 years, MetroPlus has been
committed to building strong relationships with its members and
providers to enable New Yorkers to live their healthiest life.
Develops, prior approves, facilitates, monitors, and communicates a
care plan in partnership with the member, his/her 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, identify the risk
factors, strengths and challenges, service needs of the member to
keep him/her in their community setting.Job Description - Review
and evaluate the assessment and UAS information.
- Develop a working relationship with the PCP to be able to contact
and discuss care of the member with the PCP.
- Review assessment findings risk categories with PCP to identify
any concerns that have not been identified.
- Identify the risk factors and assign the risk category to the
- Develops with the team the individual member disaster plan
- As part of Care Management team develops a formal care plan for
all services needed for the member.
- Monitor by phone or when necessary face to face the condition of
- Identify clinical issues that require immediate clinical
assessment and/or treatment to reduce risk of unnecessary
hospitalizations, ED visits or nursing home admissions.
- Prior approve request for additional services based on
assessments and using evidence-based standards refer denial,
reduction, or limitation of service request to Medical
- Assist members with the coordination of services both within
network and outside network 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 Metro Plus members.
- Coordinate with UM department on concurrent and retrospective
- Follow up with assigned nurses for clinical updates to care
- Document within two business day 's 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 program
- Speaks to members who are delinquent in their spend-down
- Cooperates with all department within Metro Plus
- Identifies members appropriate for specialty programs.
- Performs all MLTC management activities in compliance with all
regulatory agency requirements.
- Provides information to the Manager of MLTCP on all requests from
QM department to be reviewed by QA committees
- All other tasks assigned by the Clinical Manager or Medical
DirectorMinimum Qualifications - Bachelor 's Degree (BSN) required
- Bilingual Spanish Preferred
- Two (2) to three (3) years clinical experience in certified home
health agency (CHHA), Lombardi program and/or MLTC - Registered
Nurse, Currently New York State licenseProfessional
- Integrity and Trust
- Customer Service Focus
- Functional/Technical skills
- Written/Oral Communications
Keywords: MetroPlus Health Plan, Jersey City , Care Manager, Registered Nurse (MLTC), Executive , Jersey City, New Jersey
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