RN Care Manager - Managed Long-Term Care
New York, New York
MetroPlus - 50 Water Street , FL 7

Care Manager - ED

Location: New York, NY
Employment Type: Staffing - Supplier Sourced
Contract Length: 8 weeks (54 days ≈ 8 weeks)
Shift: Not specified (job description attached)

Job Summary

The Care Manager develops, facilitates, monitors, and communicates individualized care plans in partnership with members, their families, caregivers, physicians, and providers. The role focuses on identifying risk factors, coordinating care, and ensuring members remain safe and well in their community setting.

Key Responsibilities

• Review and evaluate assessments and UAS information for members in managed care programs.
• Establish and maintain working relationships with primary care providers (PCPs) to discuss member care.
• Identify risk factors and assign risk categories to members.
• Develop formal care plans including disaster plans for members.
• Monitor member conditions at least monthly, primarily via telephone, with face-to-face visits as needed.
• Identify clinical issues requiring immediate assessment or treatment to prevent unnecessary hospitalizations, ED visits, or nursing home admissions.
• Promote quality care by ensuring members receive preventive and chronic disease management.
• Prior authorize additional services based on assessments and evidence-based standards; refer denials or limitations to Medical Director.
• Assist members with coordination of services within and outside networks, including discharge facilitation.
• Provide care coordination across the continuum of care to optimize quality of care and life.
• Collaborate with Utilization Management on concurrent and retrospective reviews.
• Follow up with assigned nurses for clinical updates to care plans.
• Document coordination notes and routine contacts within two business days according to member risk level.
• Participate in team care planning meetings.
• Resolve complaints that can be addressed within one day.
• Support Customer Service and Utilization Management with records for grievances.
• Communicate with members delinquent in spend-down payments.
• Cooperate with all departments within the organization.
• Identify members suitable for specialty programs.
• Ensure compliance with all regulatory agency requirements for managed care programs.
• Provide information for Quality Management Department reviews and committees.
• Participate in department on-call schedule on a rotating basis.

Required Qualifications

• Valid Registered Nurse (RN) license in New York State.
• Associate of Science in Nursing (ASN) or Associate Degree in Nursing (ADN).
• Minimum 1 year of Utilization Review experience, including experience within the last year.
• Experience coordinating with Utilization Management (UM) department on concurrent and retrospective reviews.
• Experience prior authorizing requests for additional services based on assessments, with referral of denial, reduction, or limitation requests to the Medical Director.
• Care Manager experience.

Additional Information

• Prior travel experience is not specified or required.
• The role involves working with managed long-term care (MLTC) and Medicaid Advantage Plan (MAP) populations.