Home Visit Care Coordinator

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 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.

Position Overview

Under the direction of the Assessment Nurse Team Lead, and in collaboration with the member's Care Manager, this role will conduct an in-person home visit for MLTC and MAP members at a 6-month interval from the member's UAS. The home visit includes a brief health assessment on medical and behavioral health topics as well as a quick environmental scan of the member's home. The information gathered during this visit will then be incorporated into the member's subsequent person-centered service plan (PCSP). This home visit is a regulatory requirement for both MLTC and MAP and ensures that the member's PCSP is completely aligned with their current needs, validated with the gathering of face-to-face data.

• Conducts home visits to all members assigned and ensures compliance with HIPAA verification
• Schedules own home visits, optimizing efficiency
• Utilizes the home visit assessment tool when speaking with the member
• In the event that a member is unwilling to have someone visit them in the home, conducts telehealth home visit using the same tool
• Escalates clinical and social issues to the members' designated Care Manager
• Accurately and timely documents member call interaction in the care management system Disease Care Management System (DCMS)
• Provides printed educational materials as appropriate
• Fulfills basic care coordination tasks for the member such as appointments, transportation, medication issues such as needing prescription or refill, DME, etc.
• Conducts other supportive activities as assigned

• Bachelor's degree from an accredited college or university in a healthcare related field is required
• Minimum of 2 years of work experience in care management/coordination, health education, health home or community-based organization required. Managed Care experience preferred

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills, knowledge of Excel, ability to navigate multiple systems