Medical Case Manager
3 days ago
Job Summary
CalOptima Health is seeking a highly motivated an experienced TEMP - Medical Case Manager (Case Mgt) to join our team. Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for CalOptima Health’s members. The Medical Case Manager will facilitate communication and coordination among all participants of the health care team and the member to ensure the services provided promote quality and cost-effective outcomes for all members along with focus on members under 21 years of age. The incumbent will be responsible for providing intensive case management primarily to a pediatric population, which includes assessment, planning, implementation, coordination, monitoring and evaluation of the member’s needs.
Position Information:
Department: Case Management
Salary Grade: 313 - $43.66 - $69.8615
Work Arrangement: Full Office
Duties & Responsibilities:
85% - Care Management
Assesses member needs using a standardized health needs assessment or health risk assessment.
Performs comprehensive, disease specific, clinical assessments of all identified cases, which includes but is not limited to, assessment of:
Member’s physical, functional, social and psychological status
Member’s cultural and linguistic needs o Caregiver resources and available benefits
Performs post-discharge assessments to identify member’s post-hospital or post-emergency department discharge needs including but not limited to:
Member’s physical, functional, social and psychological status
Member’s cultural and linguistic needs o Caregiver resources and available benefits
Follow-up provider care and ensuring scheduled appointments
Durable medical equipment and supplies o Community resources
Develops and implements a member’s specific care plan which includes prioritized Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) goals.
Reviews, modifies and updates care plans continuously to reflect the member’s needs, at minimum, annually or upon change in condition.
Schedules follow-ups to assess progress towards goals and identifies barriers to meeting goal. Provides regular outreach to assigned members along with members from a worklist and evaluates quality of service given to members according to department contact standards.
Coordinates care and services with members, members’ family members/representatives and other providers, as appropriate, including community supports and Long-Term Services and Supports (LTSS).
Communicates with Member’s physicians, specialists, community agencies and vendors to ensure coordination of services.
Facilitates referrals to behavioral health/substance use disorder services and identifies and makes referrals to LTSS department, community supports and community resources.
Facilitates and participates in Interdisciplinary Team meetings as applicable.
Collaborates with interdepartmental staff in case resolution as needed.
Identifies cases needing supervisor, manager, director or medical director review or input, routes accordingly and closes cases according to procedures and guidelines in a timely manner.
Advocates in the member’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
10% - Administrative Support
Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
Follows CalOptima Health’s protocol for documenting all case interventions.
Prepares and maintains appropriate documentation of patient care and progress within the care plan.
5% - Completes other projects and duties as assigned.
Minimum Qualifications:
Associate degree in nursing (ADN) or related field required PLUS 3 years of clinical experience and/or managed care experience required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
Preferred Qualifications:
Bachelor of Science in Nursing (BSN) degree or related field.
2 years of pediatric experience.
Certified Case Manager (CCM) certificate.
Bilingual in English and one of CalOptima Health’s defined threshold languages (Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese).
Required Licensure / Certifications:
Current, unrestricted Registered Nurse (RN) license to practice in the state of California required.
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