Children's Care Manager Registered Nurse

MetroPlus Health 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 Health network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus Health has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Care Manager (CM) is responsible for reviewing, and approving Plans of Care, CANS-NY assessments and HCBS services. The CM is also responsible for the authorization of inpatient and DME requested by Medically Fragile and Care at Home children according to UM requirement set forth by the "office of Health Insurance Programs Principles for Medically Fragile Children. The CM works with Health Home Coordinators and LDSS / VCFA to ensure proper access, level of care, level of need and continuation of care for Medically Fragile and Care at Home children.

Job Description

• Coordinates with Health Home Coordinators and LDSS / VFCA Care Managers to ensure that patient comprehensive treatment needs are met.
• Coordinates member's service needs with community agencies.
• Provide education and coaching to members' family.
• Conducts follow up quarterly assessment calls to Health Home Coordinators.
• Provide clinical guidance and support to assist member in achieving their goals.
• Have extensive knowledge of community resources / services.
• Prepares for and participates in all clinical rounds.
• Interacts with physicians and other members of the Providers' Clinical Teams for discharge planning and required DME.
• Performs telephonic care review and authorization determinations for pre-admission and continuing care with hospitals, clinics and at home services.
• Determines appropriate level of care.
• Consults with Clinical Peer Reviewers when requests for services do not meet medical necessity criteria.
• Interacts with Clinical Peer Reviewers to discuss clinical / authorization questions, alternative treatment options and concerns regarding specific cases.
• Provides information to members' families, Health Home coordinators, LDSS / VFCA, clinical and HCBS providers regarding medical benefits.
• Provides telephone triage and crisis intervention to callers and, when necessary, assists with ensuring members have access to local services and resources.
• Recognizes quality of care issues and reports them appropriately through internal and external processes.
• Perform other duties as assigned by Medical Director, Director of Children's Special Services and the Senior Director of Children's Special Services, and the Director of Children's Special Services.

Minimum Qualifications

Licensure and / or Certification Required

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