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Fraud And Waste Care Manager (RN)

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Metroplus Health PlanNew York, NY
  • 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 Hospitals MetroPlus Health 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, MetroPlus Health's network includes over 27,000 primary care providers, specialists and participating clinics.
  • For more than 30 years, MetroPlus Health 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 findings/evidence.
  • 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 potential reporting 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 preferred.
  • 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 pressure.
  • 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 Competencies: Integrity and Trust Customer Focus Functional/Technical skills Written/Oral Communication Associated topics: asn, care unit, ccu, domiciliary, maternal, neonatal, psychiatric, recovery, transitional, unit

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