Transitions of Care Manager RN

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

MetroPlus Health'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, 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 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.

Job Description

• 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 in care with the member and provider.
• Address members social determinants of health issues.
• Link members to available resources.
• 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 community supports.
• Advocate for members by assisting them to address challenges and make informed choices regarding clinical status and treatment options.
• Conduct follow up calls as per transition of care protocols.
• Employ critical thinking and judgment when dealing with unplanned issues
• 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 clinical information.
• Maintain accurate, comprehensive and current clinical and non-clinical documentation 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 evaluation process.
• Maintain professional competencies as a care manager.
• Other duties as assigned by Leadership.

Minimum Qualifications

Professional Competencies

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