RN Care Transitions Navigator

MetroPlusHealth; New York (NY); On-site; USD 85,000 - 110,000; Full time

Job summary

MetroPlusHealth in New York is seeking a Transitions of Care (TOC) Care Manager to coordinate care as members move across settings—hospitals, EDs, rehab, LTC and home health. You will assess needs, reconcile medications, and plan follow-up to prevent avoidable readmissions.

You will engage members and caregivers, develop individualized plans, communicate with primary care clinicians, and link patients to resources while maintaining timely documentation and compliance with policies.

Qualifications

• Bachelor’s Degree required.
• Minimum 2 years of care management experience in a healthcare setting or managed care.
• Ability to proficiently read and interpret medical records, claims data, pharmacy, lab reports and prescriptions.
• Ability to work closely with members and caregivers.
• Ability to work collaboratively with various team members, interdepartmentally, and leadership.

Responsibilities

• Provide care management support during transitions of care.
• Complete transitions of care assessment to identify member needs.
• Complete medication reconciliation.
• Address members’ 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 members, caregivers, and members of their care team, integrating concepts of cultural sensitivity and privacy practices.
• Ensure plans of care have individualized goals and interventions.
• Communicate plan of care with primary care physicians.
• Address gaps in care with the member and provider.
• Address members social determinants of health issues.
• Link members to available resources.
• Educate members and/or caregivers 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 support.
• Advocate for members by assisting them to address challenges and make informed choices regarding clinical status and treatment options.
• Conduct follows up calls as per transition of care protocols.
• Maintain knowledge of chronic conditions and use job aids as 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 training courses, organizational and departmental policies and procedures, and actively participate in evaluation process.
• Maintain professional competencies as a care manager.
• Other duties assigned by Leadership

Skills

Care coordination

RN eligible

Education

Bachelor’s Degree

Job description

MetroPlusHealth in New York is seeking a Transitions of Care (TOC) Care Manager to coordinate care as members move across settings—hospitals, EDs, rehab, LTC and home health. You will assess needs, reconcile medications, and plan follow-up to prevent avoidable readmissions.

You will engage members and caregivers, develop individualized plans, communicate with primary care clinicians, and link patients to resources while maintaining timely documentation and compliance with policies.