Recipient Restriction Program Care Manager (Registered Nurse)
Company: MetroPlus Health Plan
Posted on: August 3, 2022
Empower. Unite. Care.MetroPlusHealth 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.About NYC Health +
HospitalsMetroPlusHealth 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's network includes over 27,000 primary care
providers, specialists and participating clinics. For more than 30
years, MetroPlusHealth has been committed to building strong
relationships with its members and providers to enable New Yorkers
to live their healthiest life. -Position Overview The purpose of
the Recipient Restriction Program is to provide restricted
enrollees with tightly managed medical and psychosocial services. -
This is accomplished for enrolled members who demonstrate a pattern
of misusing and abusing the Medicaid program. - The Recipient
Restriction Program is designed to identify MetroPlus members who
exhibit mis-utilization abusive, and fraudulent behavior in their
receipt of Medicaid and MetroPlus benefits. - The Restricted
Recipient Care Manager reports directly to the RRP Team Leader. -
The Care Manager (CM) will provide clinical expertise in supporting
the program and in working with clinicians and care management
staff to ensure the coordination of health care services for RRP
members with their designated primary care providers/clinics,
specialists, hospital, and pharmacy.Job Description
- Review fraud, waste, or abuse allegations from whatever source
derived and conduct investigations. Typical sources of such claims
are member complaints, anonymous tips, data mining,
CVS/Caremark-Enhance Safety & Monitoring Solution (ESMS),
employees, and MetroPlus vendors.
- Utilizes CVS/ Caremark Rx Report, Medical Claim Report, claim
history, along with any other information to identify potential
patterns of misuse, abuse, fraud and/or individual circumstances
that require a medical review.
- Completes a Member Summary Assessment (MSA) Report detailing
- Assist in the review of existing members' restriction status 60
days before it expires to determine whether the member's
restriction should continue or terminate.
- The RN will present the members' case to the Recipient
Restriction Review Team (RRRT) for possible restriction of services
(medical or pharmacy) provided to the member.
- The RN may also restrict the members confirmed by OMIG to have
engaged in abusive practices. In such cases, OMIG is responsible
for providing documented evidence and other supporting
documentation as needed to support the restriction. In addition,
the RN is responsible for completing the Member Summary Assessment
(MSA) and presenting it to RRPRT.
- Coordinates referrals to Care Management once a member is
placed on Restriction.
- The RN will issue a Notice of Intent to Restrict to the member,
including the Member's Summary Assessment report, Provider Contact
list, and directions to File for Fair Hearing.
- The RN will notify the Office of the Medicaid Inspector General
(OMIG) of all restrictions imposed by MetroPlus Health; in
addition, monitor any request made by OMIG.
- Responsible for verifying and submitting the Recipient
Restriction Package to the Regulatory Department/Member Service
Department upon their request.
- Responsible for maintaining accurate and thorough records for
each case, maintaining an up-to-date case log that details the
status of all open, closed, and pending cases.
- Collaborates with legal, regulatory, or government agencies for
- Remain objective and possess strong analytical skills to assess
and evaluate the medical treatment; Prescription report claims to
determine if fraud and/or abuse is present.
- All restriction information and packets will be filed in the
respective member's Restricted Recipient Review File and maintained
by the Case Management Department. Minimum Qualifications
- Background: Registered Nurse, Bachelor's Degree in Nursing
required. - - - - - - -
- An equivalent combination of training, educational background,
and experience in related fields such as hospital, home care,
ambulatory setting, and educational disciplines. Prior experience
in Care Management in a health care and/or Managed Care setting
- Proficiency with computers navigating in multiple systems and
web- based applications.
- Must be proficient on how to use Microsoft Office applications
including Word, Excel, and PowerPoint and Outlook.
- Confident, autonomous, solution driven, detail oriented, high
standards of excellence, nonjudgmental, diplomatic, resourceful,
intuitive, dedicated, resilient and proactive.
- Strong verbal and written communication skills including
motivational coaching, influencing and negotiation abilities.
- Time management and organizational skills.
- Strong problem-solving skills.
- Ability to prioritize and manage changing priorities under
- Ability to proficiently read and interpret medical records,
claims data, pharmacy, lab reports and prescriptions required.
- If needed, ability to travel within the MetroPlus service area
to participate in facility visits, community events, home visits or
other community meetings, including conferences.
- Registered Nurse Active NYS License Required.Professional
- Integrity and Trust
- Customer Focus
- Functional/Technical skills
- Written/Oral Communication
Keywords: MetroPlus Health Plan, Hartford , Recipient Restriction Program Care Manager (Registered Nurse), Executive , Hartford, Connecticut
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