Care Coordination Liaison NY

Empower. Unite. Care.
Metro PlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

Metro PlusHealthprovides 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, Metro Plus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, Metro PlusHealthnetwork includes over 27,000 primary care providers, specialists and participating clinics.

For more than 30 years, Metro PlusHealthhas been committed to building strong relationships with its members and providers.

Position Overview:

The Care Coordination Liaison strengthens coordination between

Metro Plus Healthand  NYC Health + Hospitals (H+H) to improve care coordination, remove systemic barriers, and support better outcomes for H+H-attributed

Metro Plus Health members .

This role focuses primarily on inpatient and post-acute transitions of care, with an emphasis ontimelyinformation exchange, proactive member outreach, and coordination across

Metro Plus Health Care  Management teams, H+H providers, contact center teams, and care teams. The Care Coordination Liaison supports care teams and members through targeted interventions, especially for H+H-attributed Medicare/MAP members hospitalized at non-H+H facilities.

Under the direction of the Senior Director of Integrated Care Management, the Care Coordination Liaison is a member of a team that provides care coordination services to our Metro Plus Health  members wo are attributed to and receiving care at NYC Health + Hospitals (H+H) to improve quality of care, collaboration and communication between the systema and the health plan. The Care Coordination Liaison will engage with the member and the member’s care team to improve their health and connect to community resources that will support their well-being to ensure quality outcomes (i.e., reduction in emergency room visits and hospital admissions, improved member satisfaction, closing and reducing Gaps in Care) and cost effectiveness.

9:00 AM - 5:00 PM

• Facilitates bidirectional communication betweenH+H providers and Metro Plus Health Care  Management teams primarily by email and Epic in-basket, triaging issues and inquiries and providing timely responses to messages to rapidly resolve challenging care management issues.
• Supports care transitions across settings, including emergency department, inpatient, skilled nursing/rehab, home health, and extramural facilities by serving as a designated point of contact to ensure communication is focused and appropriately directed.
• Ensures continuity of care through timely appointment scheduling; integration of discharge summaries into EPIC; provider and/or member/caregiver notifications, outreaches and follow ups, primarily using Epic messaging; and escalates untimely appointment access as needed
• Conducts targeted outreach to select members at risk of readmission and those requiring assistance with appointments, transportation, Durable Medical Equipment (DME), medication, social drivers of health, and related care coordination needs.
• Collaborates with care management leadership and multidisciplinary teams to identify and track recurring complex care management challenges and systemic barriers, especially those that require coordination across teams; support cross-organizational solutions that can improve patient/ member outcomes.
• Maintains accurate, comprehensive, and current clinical and non-clinical documentation in the care management system, Epic and/or other applicable systemsin accordance with professional standards, regulatory guidelines, and departmental expectations.
• Participates in interdisciplinary rounds and meetings to coordinate member care as needed.
• Provides support to Metro Plus Health departments  regarding member retention,utilization management, quality management, customer service, provider relations, and other member-related concerns as needed.
• Comply with orientation requirements, annual and mandatory training, organizational and departmentalpoliciesand…