MetroPlus Case Manager Lvl

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 40 years, MetroPlusHealth has been committed to building strong relationships with its members and providers.

Purpose of Position:

Under direction, optimizes members’ quality of care, their care experience, and cost savings through the
assessment and evaluation of members’ needs and circumstances; enhanced engagement and improved
access to resources; and appropriate utilization and quality management. Serves as a member advocate,
accompanying and providing comprehensive planning and support for members throughout their care journey,
from members’ homes to health care and community settings and other relevant locations. Manages medical
costs through timely prospective, concurrent, and retrospective review and research activities, and ensures
compliance with all relevant laws, rules, policies, procedures, and standards of care.

9:00 A.M – 5:00 P.M

 

Assignment Level I
Under direction, with significant latitude for independent judgement and decision making, performs assigned
duties related to assessing members’ clinical, social, financial, environmental and/or safety needs; addressing
member challenges/issues; facilitating and monitoring members’ care progress; and managing costs.
Essential Duties and Responsibilities:
1. Travels to and meets with members of varying ages, clinical scenarios, cultures, financial means, social
supports, and motivations to gain in-depth understanding of their situations, including conducting initial and
ongoing clinical assessments.
2. Prepares evidence-based, member-oriented plans of care with members, caregivers, and health care
providers; appropriately integrates principles of cultural sensitivity, high-touch care, and privacy; and regularly
communicates plans of care updates to Primary Care Physicians and other providers.
3. Supports appropriate care coordination across the continuum of care by conducting telephonic and in-person
member outreach activities, assisting members with the coordination of services from various settings, and
generating referrals to providers, community-based services, and other resources.
4. Researches available care options, while carefully considering appropriateness and costs, and promoting
alternative care programs/treatment services, when practicable.
5. Assesses risks and gaps in care, and works collaboratively with clinical providers and others to maximize
access to available resources and resolve problems related to members’ clinical, psychosocial, financial, and
environmental needs.
6. Educates members and caregivers on relevant topics, including chronic diseases, preventive care, risk
reduction, medication adherence/management, and home safety; and may be responsible for researching
and educating providers on medication and treatment compliance and alternative care options.
7. Promotes and facilitates a multidisciplinary approach, supporting collaboration and coordinated care
operations between clinical and non-clinical areas and various operating departments and programs.
8. Advocates for and engages members in a collaborative relationship, assisting them to address challenges
and make informed choices regarding clinical statuses and treatment options, and empowering them to
manage their physical, psychosocial, and environmental health.
9. Communicates directly with providers/designees, when appropriate, to gather all clinical information needed
to determine the medical necessity of requested services; consults with Medical Director concerning cases
that do not meet medical necessity or appropriate level(s) of care.
10. Provides complex case management, including but not limited to ensuring access to care, reducing
unnecessary hospitalizations, and appropriately referring to community supports.

11. Identifies potentially high-risk and fragile medical and behavioral cases, and coordinates with superiors 
colleagues to provide an integrated approach to case management.
12. Ensures continuity of care by appropriately communicating information concerning follow-up appointments
and discharge aftercare, identifying barriers to discharge planning, and working collaboratively with other
departments/teams, members, providers, and other health care setting staff to remove identified barriers.
13. Maintains accurate, comprehensive and current clinical and non-clinical documentation, and ensures that
goals, interventions, and care coordination and case management activities for each member are
documented in the electronic health record.
14. Tracks and trends outcomes and other clinical data, and presents statistics and advice on trends in internal
departmental meetings and in other forums, as necessary.
15. Performs other related duties, as assigned.

1. One (1) year of experience in case management, care coordination, discharge planning, utilization management/review, quality assurance/management, or a closely related area in a health or managed care setting; and a doctoral degree in Psychology or a related discipline from an accredited college or university, or one of the following may be substituted for a doctoral degree:
a. A valid Credentialed Alcoholism and Substance Abuse Counselor (CASAC) Level I, Level II, Advanced, or Master issued by the NYS Office of Addiction Services and Supports (OASAS).
b. A valid license and current registration to practice as a Licensed Mental Health Counselor (LMHC), Licensed Master Social Worker (LMSW), or Licensed Clinical Social Worker (LCSW) issued by the New York State Education Department (NYSED).

2. Positions supporting behavioral health, Health and Recovery Plan (HARP), and children’s special services functions require three (3) years of experience, as described in 1. above, and a valid license and current registration to practice as a Licensed Mental Health Counselor (LMHC), Licensed Marriage and Family Therapist (LMFT), Licensed Master Social Worker (LMSW), or Licensed Clinical Social Worker (LCSW) issued by the New York State Education Department (NYSED).

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• Loan Forgiveness Programs for eligible employees
• College tuition discounts and professional development opportunities
• College Savings Program 
• Union Benefits for eligible titles 
• Multiple employee discounts programs
• Commuter Benefits Programs