Head of Clinical Comprehensive Care & Quality
Job Ref: 45663
Category: Utilization Review and Case Management
Department: CASE MANAGEMENT PROGRAM
Location: New York, NY
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $115,000.00
Salary Range: $115,000.00 - $130,000.00
MetroPlus Health Plan 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’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
The primary goal of the Comprehensive Care & Quality Director is to oversee the CM Task-force team, build and implement the Social Determinants of Health (SDH) program and manage the most compromised high-risk members with the goal to optimize their health care with expected cost savings due to improve quality care. Under the direction of the Sr. Director of Clinical Services, the Comprehensive Care & Quality Director serves as subject matter expert to ensure members receive the right care in the most appropriate setting. This is accomplished through the day to day oversight of the CM taskforce and SDH staff, the identification of cases that meet criteria, conducting field visits (member’s home, facilities and provider offices) and active participation in weekly interdisciplinary meetings to provide the team with comprehensive information that will foster the most appropriate plan of care to help members reach their health potential. The interdisciplinary team is comprised of high-level health plan leaders including the Chief Medical Officer of the health plan. The Comprehensive Care & Quality Director is responsible for identifying strategies to meet overall program goals and to develop policies and procedures to ensure program elements are implemented effectively.
The Comprehensive Care & Quality Director works with Medical Management, Case Management and Behavioral Health Leadership, as well as other leaders of the organization, providers and community-based organizations to ensure vulnerable members have access to available resources and expertise.
This is a hands-on, approximately 70% field-based position and will require travel within the MetroPlus Health Plan service area.
- Manages the CM task-force team to ensure the highest risk members receive comprehensive care management.
- Builds and implements the Social Determinant of Health Program which is a new program designed to meet the psychosocial needs of members (i.e. housing, food). Provides day to day oversight of the SDH staff.
- Develops and maintains partnerships with Community Based Organizations (CBOs), Human Resources Administration (HRA), Department of Homeless Services and other state agencies.
- Develops policies and procedures to ensure processes are implement efficiently.
- Evaluates the program and implements continuous quality improvement strategies to meet desired outcome goals.
- Identifies cases that meet criteria for review and care management based on established criteria.
- Researches and evaluates clinical and non-clinical information to provide comprehensive case presentation to the interdisciplinary leadership team.
- Serves as an active member of the interdisciplinary review team to provide clinical expertise and feedback obtained from field visits to establish a plan to help members reach their optimal health.
- Physically meet members where they are to gain deep understanding of their situation and needs.
- Provide comprehensive care management including but not limited to assessment to determine the most appropriate health care needs, engaging with physicians and other members of the health care team and appropriately referring to community supports.
- Provide services to members of varying age, clinical scenario, culture, financial means, social support and motivation.
- Engage members/caregivers in a collaborative relationship, empowering them to manage their physical, psychosocial and environmental health to improve and maintain lifelong well-being.
- Maximize member’s access to available resources.
- Educate member on relevant chronic disease, preventive care, medication management (medication reconciliation and adherence), home safety, etc.
- Advocate for member by assisting them to address challenges, and make informed choices regarding clinical status and treatment options.
- Develop collaborative relationships with clinical providers and facility staff.
- Periodically review case selection criteria and processes and make recommended changes to maximize outcomes.
- Work with members of the interdisciplinary high dollar team, Medical Management and Behavioral Health leadership to develop strategies and best practices that lead to desired goals and objectives.
- Employ critical thinking and judgement when dealing with unplanned issues.
- Maintain accurate, comprehensive and current clinical and non-clinical documentation.
- 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 Clinical Lead.
- Other duties as assigned by the Sr. Director of Clinical Services or Chief Medical Officer/Designee.
- Use expert verbal and non-verbal communications skills to motivate and gain co-operation of members and their caregivers
- linical background: Advance Practice Nurse (Family or Adult Nurse Practitioner) required
- Master’s degree required
- Minimum of 2 years of experience as an advance practice nurse in a health care setting
- Field experience required; Managed Care a plus
- Proficiency with computers navigating in multiple systems and web based applications
- Confident, autonomous, solution driven, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, resilient and proactive
- Strong verbal and written communication skills including motivational coaching, influencing and negotiation abilities
- Excellent time management and organizational skills
- Strong problem solving skills
- Ability to prioritize and manage changing priorities under pressure
- Proficient in Microsoft Office applications including Word, Excel, PowerPoint and Outlook.
- Ability to proficiently read and interpret medical records, claims data, pharmacy and lab reports, and prescriptions required
- Ability to travel within the MetroPlus service area making home visits to members, facility visits to clinical providers, and visits to community, faith and other social service based agencies.
- Ability to work closely with member and caregiver.
- Ability to work in a facility based environment collaborating with all levels of Health Care Providers, members and families.
- Ability to form effective working relationships with all stakeholders.
Licensure and/or Certification Required
- Advance Practice Nurse (Family or Adult Nurse Practitioner) required
- Integrity and Trust
- Customer Focus
- Functional/Technical skills
- Written/Oral Communication
How To Apply
If you wish to apply for this position, please apply online by clicking the "Apply Now" button or forward your resume, noting the above Job ID #, to:
MetroPlus Health Plan
Human Resources Department
160 Water Street 8th Floor
New York, NY 10038
Attn: Recruitment Unit