- Performs care management including hospital admission certification, continued stay review, discharge planning, out-patient and ancillary services review, etc., following established MetroPlusHealth Utilization Management policies, procedures and protocols
- Oversees the coordination and delivery of comprehensive, quality health care and services for all members requiring care management in a cost-effective manner
- Interacts and obtains relevant clinical information from member’s 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
- Evaluates 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
- Participates in Medical Management grand rounds with the Physician Advisor
Foreign medical school graduates considered
The Care Manager, working under the direction of the Director of the Department of Utilization Management, 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 both outpatient and inpatient services. 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.
"The Case Management Team is exceptional. There is wonderful departmental leadership. The team leads are supportive and professional. There are many well-trained staff with a variety of skills. The training offered is valuable for professional development. ... Overall, people there are very nice and friendly. Solid place for good work life."
Current Employee / Manager in New York, NY says:
"Diverse workforce with some very talented managers and staff. A great place to learn if you are energetic and passionate. A great deal of opportunity for those that work hard and accomplish goals."
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Equal Opportunity Employer