Healthfirst
Care Manager, RN - Restricted Recipient Program
Healthfirst, Trenton, New Jersey, United States
Care Manager, RN - Restricted Recipient Program
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Care Manager, RN - Restricted Recipient Program
role at
Healthfirst .
The Care Manager plans, manages, and/or coordinates physical and behavioral care with members, collaborating with clinicians and healthcare team members. This role will support a variety of areas including the Recipient Restriction Program (RRP) for enrollees who have presented a pattern of abusing and misusing the Medicaid program, unsuppressed HIV+ members, hemophilia, and episodic engagement. The work with the RRP enrollees will include facilitating medical and psychosocial care and addressing identified member needs across the continuum of care. Other areas of care‑management support will include complex care‑risk members involving product lines such as CompleteCare, SNP, Medicaid‑Medicare, PHSP, HARP, etc. The Care Manager is responsible for applying care‑management principles when engaging members and addressing coordination of the member’s health care services. Depending on residence and line of business, the Care Manager may be expected to make home, nursing home, and other related site visits around downstate New York.
Duties / Responsibilities Of The Restricted Recipient Program
Oversees the care management of members in the NYS RRP who require tightly managed access to medical services due to historic misuse 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/cost members and RRP Committee‑referred members to improve health outcomes, coordination of benefits, and social determinants of health.
Attends clinical rounds with medical providers and interdisciplinary team.
Provides programmatic case management to complex care‑risk 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 with the multi‑disciplinary health care team to ensure care plan goals are achieved and maximize member outcomes.
Identifies 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 according to internal and established documentation procedures; follows up as needed and updates care plans based on member needs.
Occasional overtime as necessary.
Additional duties as assigned.
Minimum Qualifications
NYS Registered Nurse (RN)
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 the frail adult population 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.
Proficient with simultaneously navigating the Internet and multi‑tasking with multiple electronic documentation systems.
Experience using Microsoft Excel with the ability to edit, search, sort, filter, and other Microsoft and PHI systems.
Hiring Range
Greater New York City Area (NY, NJ, CT residents): $81,099 - $117,466
All Other Locations (within approved locations): $71,594 - $106,080
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. Healthfirst offers employees a full range of benefits such as medical, dental, and vision coverage; incentive and recognition programs; life insurance; and 401(k) contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
The hiring range is defined as the lowest and highest salaries that Healthfirst would in good faith pay to a new hire, a promotion, or a transfer into this role.
Seniority level: Not Applicable
Employment type: Full‑time
Job function: Health Care Provider
Industries: Hospitals and Health Care
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Care Manager, RN - Restricted Recipient Program
role at
Healthfirst .
The Care Manager plans, manages, and/or coordinates physical and behavioral care with members, collaborating with clinicians and healthcare team members. This role will support a variety of areas including the Recipient Restriction Program (RRP) for enrollees who have presented a pattern of abusing and misusing the Medicaid program, unsuppressed HIV+ members, hemophilia, and episodic engagement. The work with the RRP enrollees will include facilitating medical and psychosocial care and addressing identified member needs across the continuum of care. Other areas of care‑management support will include complex care‑risk members involving product lines such as CompleteCare, SNP, Medicaid‑Medicare, PHSP, HARP, etc. The Care Manager is responsible for applying care‑management principles when engaging members and addressing coordination of the member’s health care services. Depending on residence and line of business, the Care Manager may be expected to make home, nursing home, and other related site visits around downstate New York.
Duties / Responsibilities Of The Restricted Recipient Program
Oversees the care management of members in the NYS RRP who require tightly managed access to medical services due to historic misuse 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/cost members and RRP Committee‑referred members to improve health outcomes, coordination of benefits, and social determinants of health.
Attends clinical rounds with medical providers and interdisciplinary team.
Provides programmatic case management to complex care‑risk 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 with the multi‑disciplinary health care team to ensure care plan goals are achieved and maximize member outcomes.
Identifies 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 according to internal and established documentation procedures; follows up as needed and updates care plans based on member needs.
Occasional overtime as necessary.
Additional duties as assigned.
Minimum Qualifications
NYS Registered Nurse (RN)
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 the frail adult population 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.
Proficient with simultaneously navigating the Internet and multi‑tasking with multiple electronic documentation systems.
Experience using Microsoft Excel with the ability to edit, search, sort, filter, and other Microsoft and PHI systems.
Hiring Range
Greater New York City Area (NY, NJ, CT residents): $81,099 - $117,466
All Other Locations (within approved locations): $71,594 - $106,080
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. Healthfirst offers employees a full range of benefits such as medical, dental, and vision coverage; incentive and recognition programs; life insurance; and 401(k) contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
The hiring range is defined as the lowest and highest salaries that Healthfirst would in good faith pay to a new hire, a promotion, or a transfer into this role.
Seniority level: Not Applicable
Employment type: Full‑time
Job function: Health Care Provider
Industries: Hospitals and Health Care
#J-18808-Ljbffr