Transitions of Care Manager RN

MetroPlusHealth's 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.

Position Overview

The primary goal of the Transitions of Care (TOC) Care Manager is to provide care coordination services as members move from one setting to another. Examples of these settings include inpatient facilities, emergency department, rehabilitation facilities, long-term care facilities, and certified home health agencies. The goal is to prevent re-admissions and reduce avoidable admissions. This is accomplished through engagement and understanding of members' need, environment, providers, support system and optimization of services available to them. In addition, ensuring follow up appointments are scheduled, conducting medication reconciliation, and providing education related to members condition and necessary steps to remain safely in the community. The TOC Care Manager is expected to assess and evaluate member needs, be a creative, efficient and resourceful problem solver. In collaboration with the members' care team, a plan of care with individualized goals and interventions is updated, implemented and evaluated.

• Provide care management support during transitions of care.
• Complete transitions of care assessment to identify member needs.
• Complete medication reconciliation.
• Address member's problems and needs: clinical, psychosocial, financial,environmental.
• Engage members in a collaborative relationship, empowering them to self-manage their physical, psychosocial and environmental needs.
• Prepare member-oriented plan of care with member, caregiver, and members of their care team, integrating concepts of cultural sensitivity and privacypractices.
• Ensure plans of care have individualized goals and interventions.
• Communicate plan of care with primary care physician.
• Address gaps incare with the member and provider.
• Address members social determinants of health issues.
• Link members to availableresources.
• Educate member and/or caregiver on relevant chronic diseases, preventive care, medication management (medication reconciliation and adherence), home safety,etc.
• Ensure access to care, reducing unnecessary hospitalizations, and appropriately referring to communitysupports.
• Advocate for members by assisting them to address challenges and make informed choices regarding clinical status and treatmentoptions.
• Conduct follow up calls as per transition of care protocols.
• Employ critical thinking and judgment when dealing with unplannedissues
• Maintain knowledge of chronic conditions and use job aids as a guidance.
• Ability to use data as a tool in tracking and trending outcomes and clinicalinformation.
• Maintain accurate, comprehensive and current clinical and non-clinicaldocumentation in the care management system.
• Comply with all orientation requirements, annual and other mandatory trainings,organizational and departmental policies and procedures, and actively participate in evaluationprocess.
• Maintain professional competencies as a care manager.
• Other duties as assigned byLeadership.

• Bachelor's Degree required.
• Minimum 2 years of care management experience in a healthcare setting or in a managed care organization.
• Ability to proficiently read and interpret medical records, claims data, pharmacy,lab reports and prescriptionsrequired.
• Ability to work closely with member andcaregiver.
• Ability to work collaboratively with various team members, interdepartmentally, and leadership
• Registered Nurse with current NYS license

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

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