Care Manager (DC Medicaid) in Washington, DC – CareFirst


Resp & Qualifications

 The Hospital Transitions Coordinator (HTC) is assigned to a specific hospital, facility or region to oversee the Total Care and Cost Improvement (TCCI) Program, as follows:  

  1. Supports the Hospital Transition of Care Program for targeted enrollees including acute, post-acute, ensures the coordination and continuity of health care as enrollees transfer between different locations or levels of care.
  2. Accountable for improving coordination between enrollees, providers and caregivers through communication and follow up
  3. Provides rapid triage to the appropriate TCCI, including but not limited to Complex Care Management, Wellness Navigation, Disease Management, Home Based Services, and Medication Therapy Management Review to best address ongoing health needs of the enrollee.
  4. Supports the TCCI Program for all hospitalized CareFirst enrollees, ensures the coordination and continuity of health care as enrollees transfer between different locations or levels of care
  5. Ensure Enrollees have a Primary Care Provider (PCP) or Specialist appointment scheduled for a post-discharge appointment before the Enrollee is discharged from the hospital.
  6. Conduct a clinical assessment of the Enrollee and determine if the Enrollee has ongoing care needs.
  7. Performs concurrent review for CareFirst enrollees in accordance with the length of stay guidelines outlined for the Hospital Transition of Care Program.
  8. Consults with the Medical Directors for medical necessity determinations and appropriateness of care.

PRINCIPAL ACCOUNTABILITIES:  Under the general direction of the Manager of Care Management, the incumbent’s accountabilities include, but are not limited to, the following:

(Note: Incumbent may be assigned to work onsite at one or more hospitals or may be assigned to one or more hospitals to perform the essential job functions and engage with enrollees, families, and providers telephonically.)

– Rapidly triages enrollees into identified levels of care, as appropriate.

  • Understands the Total Care and Cost Improvement (TCCI) Program concept and protocols and can advocate for the enrollee.
  • Contemporaneously, identifies enrollees for program participation based on program guidelines, analytics and use of sound clinical judgment.
  • Engages enrollees to participate in appropriate TCCI programs, establishes relationship and follows up for ongoing coordination and assessment
  • Assures enrollee understanding of adequate support upon transition and knowledge of who to call if problem arise. Collaborates with facility staff as necessary to close gaps when identified.

– Implements an effective TCCI program for enrollees identified based on their appropriate level.

  • Works with the hospital Admitting Office, Emergency Department, Registration and with CareFirst’s iCentric Portal/CRISP to identify CareFirst Enrollees who have been admitted
  • Depending on whether the HTC is onsite or telephonic, meets/engages with identified enrollees while hospitalized.  Discusses and reviews the discharge plan, addresses enrollee concerns, and proactively anticipates enrollee needs at hospital discharge.
  • Contacts hospital discharge planner, liaison, case manager or Local Care Coordinator/Behavioral Health Care Coordinator during the triaged enrollee’s hospitalization. Discusses and reviews the discharge plan.
  • Contacts identified CareFirst enrollees post discharge and actively follow up to verify the transition plan and care connections.
  • Coordinates necessary interventions.
  • Communicates with Case Management when enrollees are attributed to improve the care connections. Aids those enrollees who do not have a primary care practitioner to select a provider for care coordination and improved outcomes through the CareFirst website.
  • Primary role as coordinator/facilitator—proactively guiding enrollees to the appropriate CareFirst programs and resources, to achieve program goals of reduced readmissions, cost-efficiency and quality outcomes. 
  • Ensures the transition of care from one setting to another for identified CareFirst enrollees.  Provides enrollee interventions such as verifying appointments and coordinating medically necessary home health services.
  • Aids enrollees and providers for alternative settings of care.

– Communicates and interacts professionally with physicians, other providers, and enrollees.

  • Builds and maintains a solid professional relationship with all targeted facilities (especially with hospitalists and Emergency Department physicians) and is proficient and knowledgeable about the Care Transition model. Communicates regularly on operational issues/concerns and barriers.
  • Improves communication during transitions between providers, enrollees and caregivers to assure smooth transitions.
  • Provide timely and accurate communication of information as enrollees move from one level of care to another.


Required Licensure/Education/Experience/Skills/Abilities: 


  • Basic understanding of the strategic and financial goals of a health care system or payor organization. Basic understanding of health plan or health insurance operations (e.g. networks, eligibility, benefits).
  • Must be capable of working with minimal oversight, showing keen attention to detail and making critical decisions to ensure enrollees have an effective plan of care that leads to optimal, cost-effective outcomes.
  • Must have excellent analytical and problem-solving skills, excellent organizational, communication and coordination skills. 
  • Must have effective presentation, negotiation and influencing skills to interface with all levels of management and physician practices. 
  • Must be able to apply complex problem-solving abilities to achieve problem and process solutions.
  • Excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for enrollees.
  • Knowledgeable of available community resources and programs.
  • Must be able to effectively work in a fast- paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
  • Flexibility to work varied hours, and ability to travel by own means to a variety of locations to support business needs and to attend business meetings.

The incumbent is required to have had the vaccinations listed below and been appropriately screened (and cleared) for the items listed below.  If the incumbent has not had them or been screened and cleared, they must do so upon acceptance of offer:

  • TB screening (and repeat annually)
  • MMR-V Immunity
  • Influenza Vaccine (Seasonal)
  • COVID-19 vaccine series completed

The incumbent is required to complete the following training as assigned by Management, including, but not limited to:

  • Infection control basics
  • TB Awareness
  • Bloodborne Pathogens (and repeat annually)

** Hospital Assignments are subject to change based on evolving business needs.


  • The physical demands described here are representative of those that must be met by the incumbent to perform the essential duties and responsibilities of the position successfully.  Requirements may be modified to accommodate individuals with disabilities.
  • Must be able to provide face to face contact with inpatient enrollee at assigned hospital facility.
  • Must provide own transportation to drive to satellite CareFirst Blue Cross Blue Shield offices and/or assigned facility and to attend onsite any required meetings, trainings, or other assigned functions, at designated CareFirst office.
  • Walking and standing is required.  Lift weight up to 25 pounds on occasion.
  • Hands are regularly used to write, type, key and handle or feel small controls and objects.  Must be able to type and to speak on the telephone simultaneously.
  • Must have the ability to communicate verbally effectively. Auditory ability to actively listen.

Potential Job Hazards:

The position could be located within an inpatient hospital facility. 

  • Incumbents are required to state their purpose upon arrival to the enrollee’s room so there is no confusion as to their role vs. the role of the direct care hospital staff. 
  • Incumbents do not provide any form of direct patient care.

Airborne Exposure:

There is the potential for exposure to airborne illnesses, such as, but not limited to, tuberculosis, measles, mumps, rubella, varicella and influenza.  The following administrative controls are in place to limit or minimize exposure potential:

  • Incumbents do not enter any inpatient rooms, or hospital rooms designated with Respiratory precautions, or where any procedures are being done that produce respiratory droplets.
  • Incumbents are required to always remain at least 3 feet away from the inpatient enrollee.

Bloodborne Pathogens:

There is always the potential for exposure to Bloodborne Pathogens if not aware of surroundings.  The following administrative controls are in place to limit or minimize exposure potential:

  • Incumbents do not touch enrollees;
  • Incumbents must always practice Universal Precautions.

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 8.19.21

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship


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