Healthfirst
Care Manager, RN - Restricted Recipient Program
Healthfirst, Hartford, Connecticut, United States
Care Manager, RN - Restricted Recipient Program
Location: Downstate New York. This role plans, manages or coordinates physical and behavioral care for members, including the Restricted Recipient Program (RRP) for enrollees with Medicaid misuse, HIV+, hemophilia, and complex care.
Responsibilities
Oversees the care management of members in the NYS RRP who require tightly managed access to medical services due to their historic misuse or abuse of Medicaid program resources.
Conducts medical reviews of member usage patterns, analyzing for fraud, waste, or abuse trends to determine whether restrictions should be applied, remain, or be lifted.
Participates in RRP Committee meetings; presenting member updates as needed.
Provides care management to high risk members, improving health outcomes, coordination of benefits, SDOH, and members referred by families or providers.
Attends Clinical Rounds with medical providers and interdisciplinary team.
Provides programmatic case management to complex care members, including those who are HIV+ and viral load unsuppressed.
Advocates, informs, and educates beneficiaries on services, self‑management techniques, and health benefits.
Conducts assessments to identify barriers and opportunities for intervention.
Develops care plans that align with the physician’s treatment plans and recommends interventions that align with proposed goals.
Generates referrals to providers, community‑based resources, and appropriate services to assist in goal achievement.
Collaborates with provider doctors, social workers, discharge planners, and community based service providers to coordinate care accordingly.
Coordinates and facilitates the multidisciplinary health care team to ensure care plan goals are achieved and maximize member outcomes.
Assists in identifying opportunities for alternative care options based on member needs and assessments.
Evaluates service authorizations to ensure alignment and execution of the member’s care and physician treatment plan.
Contributes to corporate goals through ongoing execution of member care plans and member goal achievement.
Documents all encounters with providers, members, and vendors in the appropriate system in accordance with internal and established documentation procedures; follows up as needed; and updates care plans based on member needs, as appropriate.
Occasional overtime as necessary.
Additional duties as assigned.
Minimum Qualifications
NYS RN license.
Preferred Qualifications
Strong interpersonal and assessment skills, especially the ability to relate well with seniors, their families, and community care providers, and demonstrated ability to handle rapidly changing crisis situations.
Fluency in Spanish, Korean, Mandarin, or Cantonese.
Knowledge and experience with current community health practices for frail adult populations and cognitively impaired seniors.
Knowledge of InterQual and LOCADTR.
Experience managing member information in a shared network environment using paperless database modules and archival systems.
Experience and knowledge of the relevant product line.
Relevant work experience preferably as a Care Manager.
Demonstrated ability to manage large caseloads and effectively work in a fast‑paced environment.
Proficiency with simultaneously navigating the internet and multi‑tasking with multiple electronic documentation systems.
Experience using Microsoft Excel with ability to edit, search, sort, filter and other PHI systems.
Compensation & Benefits Greater New York City Area (NY, NJ, CT residents): $81,099 - $117,466. All other approved locations: $71,594 - $106,080. Healthfirst offers employees a full range of benefits such as medical, dental, vision coverage, incentive and recognition programs, life insurance, and 401k contributions. Salaries and compensation are contingent upon experience, education, licenses, and certifications.
Employment Type Full‑time.
Seniority Level Not Applicable.
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Responsibilities
Oversees the care management of members in the NYS RRP who require tightly managed access to medical services due to their historic misuse or abuse of Medicaid program resources.
Conducts medical reviews of member usage patterns, analyzing for fraud, waste, or abuse trends to determine whether restrictions should be applied, remain, or be lifted.
Participates in RRP Committee meetings; presenting member updates as needed.
Provides care management to high risk members, improving health outcomes, coordination of benefits, SDOH, and members referred by families or providers.
Attends Clinical Rounds with medical providers and interdisciplinary team.
Provides programmatic case management to complex care members, including those who are HIV+ and viral load unsuppressed.
Advocates, informs, and educates beneficiaries on services, self‑management techniques, and health benefits.
Conducts assessments to identify barriers and opportunities for intervention.
Develops care plans that align with the physician’s treatment plans and recommends interventions that align with proposed goals.
Generates referrals to providers, community‑based resources, and appropriate services to assist in goal achievement.
Collaborates with provider doctors, social workers, discharge planners, and community based service providers to coordinate care accordingly.
Coordinates and facilitates the multidisciplinary health care team to ensure care plan goals are achieved and maximize member outcomes.
Assists in identifying opportunities for alternative care options based on member needs and assessments.
Evaluates service authorizations to ensure alignment and execution of the member’s care and physician treatment plan.
Contributes to corporate goals through ongoing execution of member care plans and member goal achievement.
Documents all encounters with providers, members, and vendors in the appropriate system in accordance with internal and established documentation procedures; follows up as needed; and updates care plans based on member needs, as appropriate.
Occasional overtime as necessary.
Additional duties as assigned.
Minimum Qualifications
NYS RN license.
Preferred Qualifications
Strong interpersonal and assessment skills, especially the ability to relate well with seniors, their families, and community care providers, and demonstrated ability to handle rapidly changing crisis situations.
Fluency in Spanish, Korean, Mandarin, or Cantonese.
Knowledge and experience with current community health practices for frail adult populations and cognitively impaired seniors.
Knowledge of InterQual and LOCADTR.
Experience managing member information in a shared network environment using paperless database modules and archival systems.
Experience and knowledge of the relevant product line.
Relevant work experience preferably as a Care Manager.
Demonstrated ability to manage large caseloads and effectively work in a fast‑paced environment.
Proficiency with simultaneously navigating the internet and multi‑tasking with multiple electronic documentation systems.
Experience using Microsoft Excel with ability to edit, search, sort, filter and other PHI systems.
Compensation & Benefits Greater New York City Area (NY, NJ, CT residents): $81,099 - $117,466. All other approved locations: $71,594 - $106,080. Healthfirst offers employees a full range of benefits such as medical, dental, vision coverage, incentive and recognition programs, life insurance, and 401k contributions. Salaries and compensation are contingent upon experience, education, licenses, and certifications.
Employment Type Full‑time.
Seniority Level Not Applicable.
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