Care Manager - Utilization Review/Management - New York, NY

MetroPlus Health Plan, Inc.; New York (NY); Remote; USD 90,000 - 120,000; Full time

Job summary

MetroPlusHealth in New York seeks a Care Manager to coordinate care across inpatient and outpatient settings, aiming to achieve high-quality patient outcomes while minimizing unnecessary expenses.

You will collaborate with PCPs and providers to direct care to the most appropriate setting, evaluate outcomes, and support members through outreach. The role requires a NYS license as RN, LPN, or PT and 2–5 years of clinical experience in an acute or applicable care setting.

Qualifications

• New York State license as Registered Nurse, Licensed Practical Nurse, or Physical Therapist.
• High School Diploma or GED required.
• 2–5 years of clinical experience in an acute or applicable care setting.
• UM/UR experience in managed care or hospital setting required.

Responsibilities

• Performs care management including admission certification, continued stay review, discharge planning, and services review.
• Oversee coordination and delivery of quality healthcare for all members in a cost-effective manner.
• Obtain clinical information from members’ PCP and providers; approve care meeting criteria; refer others to Medical Director.
• Identify utilization trends and member needs through reports and health assessment forms.
• Ensure utilization management activities comply with regulatory requirements.

Skills

Integrity and Trust

Customer Focus

Communication skills

Analytical skills

Job description

Position Overview

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. 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.

Duties & Responsibilities

• 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 assigned

Minimum Qualifications

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

Professional Competencies

• Integrity and Trust
• Customer Focus
• Excellent communication, written and analytical skills.
• Knowledge of computer systems.

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