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Case Manager, High Risk RN
3 months ago
Position Summary:
The Outpatient Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified High Risk members. The Outpatient Case Manager will assess and develop a care plan in collaboration with the admitting, attending and consulting physician, the member and other health care practitioners. The goal of the Outpatient Care Manager is to effectively manage members on an outpatient basis to assure the appropriate level-of-care is provided, to prevent in patient admission and re-admissions, and ensure that the members’ medical, environmental, and psychosocial needs are met over the continuum of care.
Essential Duties and Responsibilities include the following:
- Keeps member/family members or other customers informed and requests if necessary, further assistance when needed.
- Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
- Functions as liaison between administration, members, physicians and other healthcare providers.
- Interacts professionally with member/family/physicians and involves member/family/physicians in formation of the plan of care.
- Performs a Clinical Assessment/Questionnaire of the member and determines an acuity score for necessary scheduled follow-up.
- Develops an outcome-based plan of care, based on the member’s input and assessed member needs. Implements and evaluates the plan of care as often as needed as evidenced by documentation in the member’s case file.
- Documents member assessment and reassessment, member care plans, and other pertinent information completed in the member’s medical record in accordance with the FOCUS Charting methodology, nursing standards, and company policies and procedures.
- Initiates community visits (hospital, home visits) as needed to assess patient progress and meet with appropriate members of the patient care team.
- Identifies planned and unplanned transitions of care from Requests for Services or daily inpatient and SNF census.
- Educates the member/caregiver on the transition process and how to reduce unplanned transitions of care.
- Manages transition of care from the sending to receiving settings ensuring that the Plan of Care moves with the member and updates/modifies the care plan as the member’s health care status changes.
- Communicates appropriately and clearly with physicians, in patient case managers and Prior-Authorization nurses
- Identifies and addresses psychosocial needs of the members and family and facilitates consultations with Social Worker, as necessary.
- Identifies and addresses pharmacological needs of the members and facilitates consultations with the pharmacy department, as necessary.
- Identifies community resources to address needs not covered by the member’s benefit plan, and coordinates member benefits as needed, with the health plan.
- Participates in the efficient, effective and responsible use of resources such as medical supplies and equipment.
- Responsible for the coordination and facilitation of member and family conferences as determined by assessment of member’s needs.
- Identifies the appropriate members to participate in the interdisciplinary case round process. Prepares the necessary summary information to present to the team.
- Responsible for the coordination of clinic appointments, medication reconciliation, PCP and SPC visits.
- Ability to collaborate and communicate with all members of the healthcare team (concurrent review, pre-authorization, PCP/SPC, Social Services, Pharmacy) to coordinate the continuum of care of developing plans for management of each case.
- Responsible for the identifying members that are appropriate for hospice conversion or Palliative care.
- Meet with members/caregiver face to face in different locations (clinic, home, hospital, and community) in order to build a rapport with member so that the case manager can better support member/caregiver with care coordination and the plan of care.
- All other duties as directed by management.
The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.
Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.
Full Time Position Benefits:
The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.
Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.
Health and Wellness:
- Employer-paid comprehensive medical, pharmacy, and dental for employees
- Vision insurance
- Zero co-payments for employed physician office visits
- Flexible Spending Account (FSA)
- Employer-Paid Life Insurance
- Employee Assistance Program (EAP)
- Behavioral Health Services
- 401k Retirement Savings Plan
- Income Protection Insurance
- Vacation Time
- Company celebrations
- Employee Assistance Program
- Employee Referral Bonus
- Tuition Reimbursement
- License Renewal CEU Cost Reimbursement Program
- Business-casual working environment
- Sick days
- Paid holidays
- Mileage
Requirements
Education and/or Experience:
- Graduate from an accredited Registered Nursing Program or Licensed Vocational Nursing Program.
- Current CA RN, or LVN license, current CPR certification, valid CA Driver’s license.
- 3 years acute care or case management experience preferred.
- 2-3 years of utilization or HMO experience preferred.
- Typing 40 words per minutes with accuracy.
- Must have valid CA DL and provide proof of vehicle insurance.
- Knowledge of computers, faxes, printers and all other office equipment.
- Knowledgeable in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint)
Optional on call duties as assigned.
