Care Manager, RN - Restricted Recipient Program

The Care Manager plans, manages and/or coordinates physical and/or behavioral care with members, collaborating with clinicians and health care team members. This role will support a variety of areas including the Recipient Restriction Program (RRP) for enrollees that 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 efforts will include complex care/rising 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 one’s residence and line of business, the Care Manager may be expected to make home, nursing home, and other related sites 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 their historic misuse/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 lifted as a result.
• Participates in RRP Committee meetings; presenting member updates as needed.
• Provides care management to high risk/cost and/or RRP Committee referred members, to improve health outcomes, coordination of benefits and SDOH, and/or members referred by families or providers.
• Attends Clinical Rounds with medical providers and interdisciplinary team.
• Provides programmatic case management to complex care/rising 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 and other resources 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 as necessary in order 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

Preferred Qualifications:

• Strong interpersonal and assessment skills, especially the ability to relate well with seniors, their families, and community care providers, along with demonstrated ability to handle rapidly changing crisis situations.
• Fluency in Spanish, Korean, Mandarin, or Cantonese.
• Knowledge and experience with the current community health practices for the frail adult population and cognitive 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 docu