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Job Ref: 106940

Category: Utilization Review and Case Management

Department: MHP CHILDRENS PROGRAM

Location: 50 Water Street, 7th Floor,

New York,
NY 10004


Job Type: Regular

Employment Type: Full-Time



Salary Range: $96,682.00 - $96,682.00

Empower. Unite. Care.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

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

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.

• 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.

• Bachelor's Degree required
• A minimum of two year's clinical experience in an acute care setting
• Experience using Interqual Guidelines required.
• Knowledge of medical care and HCBS services needed by medically fragile children.

Licensure and/or Certification Required

• A valid NYS RN license

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication
• Clinical skills and subject matter knowledge.
• Must be able to learn and master UM/CM MetroPlusHealth systems and procedures.
• Customer Service
• Oral and written communication skills