MetroPlus 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 Enrollment/Assessment Nurse, identify the risk factors, strengths and challenges, service needs of the member to keep him/her in their community setting.
* 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 member.
* 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 the members.
* 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 Director.
* 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 review.
* Follow up with assigned nurses for clinical updates to care plan.
* 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 members
* Speaks to members who are delinquent in their spend-down payments.
* 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 Director
* Participates in the department on call schedule/being on call; which is rotated amongst the care team.
* Bachelor's Degree (BSN) required
* Two (2) to three (3) years clinical experience in certified home health agency (CHHA), Lombardi program and/or MLTC
Licensure and/or Certification Required
* Registered Nurse, Currently New York State license
* Integrity and Trust
* Customer Service Focus
* Functional/Technical skills
* Written/Oral Communications