Care Manager (RN/LPN)(PCS) - Utilization Management Job at MetroPlus Health Plan, New York, NY

UU5LOXZGM1QzeGFsTm4vNXBEVHF2bUxvRmc9PQ==
  • MetroPlus Health Plan
  • New York, NY

Job Description

Care Manager (RN/LPN)(PCS) - Utilization Management

Job Ref: 106457
Category: Utilization Review and Case Management
Department: UTILIZATION MANAGEMENT
Location: 50 Water Street, 7th Floor, New York, NY 10004
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $108,815.00
Salary Range: $108,815.00 - $108,815.00

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.

About NYC Health + Hospitals

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's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealthhas 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 under the direction of the Vice President of Clinical Services, is primarily responsible for managing both simple and complex medical cases to achieve high-quality patient care outcomes and minimize unnecessary medical expenses, through the coordination of services, both outpatient and inpatient.  The Care Manager will assist the provider in directing care to the most appropriate setting, evaluating alternative care plans, and assessing outcomes through outreach to the members..

Job Description

Performs care management including hospital admission certification, continued stay review, discharge planning, outpatient, and ancillary services review, etc., following established MetroPlusHealth Utilization Management policies, procedures, and protocols.

Oversee the coordination and delivery of comprehensive, quality healthcare and services for all members requiring care management in a cost-effective manner.

Interacts and obtains relevant clinical information from members’ PCP and other providers; approves care that meets established criteria; and refers all other cases to the MetroPlusHealth Physician Advisor/Medical Director. Informs member and provider of Utilization Management determinations and treatment alternatives.

Identifies utilization trends and potential member needs by means of generating reports of encounter data, pharmacy data review, and new member health assessment forms.

Evaluate member needs for referred cases (from providers or member self-referred).

Assists all departments with the resolution of members’ problems related to utilization management issues.

Performs all Utilization Management activities in compliance with all regulatory agency requirements.

Conducts medical record reviews as appropriate to case management functions.

Participate in Medical Management grand rounds with the Physician Advisor.

Performs all other duties as assign

Minimum Qualifications

High School Diploma General Equivalency Diploma (GED) required; and

2-5 years’ clinical experience in an acute or applicable care setting.

UM/UR experience in managed care or hospital setting required.

New York State license as Registered Nurse, License Practical Nurse, or Physical Therapist required

Professional Competencies

Integrity and Trust

Customer Focus

Excellent communication, written and analytical skills.

Knowledge of computer systems.

#LI-REMOTE

Job Tags

Full time,

Similar Jobs

Advanced Care Partners

EMT / ER Technician - $15-18 per hour Job at Advanced Care Partners

 ...Details\n Job Location : Fort Pierce PPEC - Fort Pierce, FL\n Position Type : Full-Time/Part-Time/PRN\n Salary Range : $15.00 - $18.00 Hourly\n Job Shift : Day\n Job Category : Nursing - PPEC\n \nDescription Calling all Emergency Medical Technicians (EMTs)!... 

Hearst

Traffic / Breaking News Anchor Job at Hearst

 ...engagement skills. We want someone who can captivate our viewers on social media and a journalist who will grow this position....  ...diverse and varied as the audience we reach, ensuring that the content we create is more compassionate, and more representative of the... 

Check Off Your List

Part-Time Remote Bookkeeper Job at Check Off Your List

 ...influence on small businesses? We are Check Off Your List, a business support team of executive assistants, marketing specialists, & bookkeepers and were looking for the right people to join our dynamic team and support our rapid growth. The Remote Bookkeepers... 

Milton Hershey School

Softball, U12 Assistant Coach Job at Milton Hershey School

 ...Description Back to all Careers JOB ID: 24000223 Hershey, PA Part-time Job Category: Athletics & Coaching Milton Hershey School...  ...begin in Elementary and Middle Division, and culminate to the Senior Division Varsity level. Our program has produced many... 

Animal Medical Clinic

Groomer Job at Animal Medical Clinic

 ...is a busy full service veterinary boarding, doggy daycare, and grooming facility. We have created a fun-loving yet professional atmosphere...  ...life insurance, paid time off, continuing education, generous pet care discounts, 401K, and much, much, more! Job requirements:...