RN Medical Case Manager

Medical Case Manager

Job Summary:

We are seeking a dedicated and experienced Case Manager to join our team. The ideal candidate will provide comprehensive case management services, facilitating communication and coordination among healthcare team members to ensure quality and cost-effective outcomes for our members. This role involves intensive case management, including assessment, planning, implementation, coordination, monitoring, and evaluation of members' needs.

Position Information:

Department: Long Term Care
Work Arrangement: Full Office
Salary: $43 - $67/HR DOE
Contract Length: 6 months

Key Responsibilities:

Program Support (95%):
Medical Review Support Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.

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.
Applies utilization management, authorizations and case management/nursing processes that include assessment, care planning collaboration, advocacy, implementation/intervention, monitoring and evaluation of a member’s status.
Participates in hospital rounds.
Collaborates with hospitals on complex discharges.
Communicates timely with CalAIM providers and members to coordinate and initiate Community Support (CS) services and (ECM) Enhanced Case Management.
Completes all documentation accurately and appropriately for data entry into the utilization management or care management system at the time of the telephone call or fax to include any authorization updates.
Reviews and evaluates proposed services utilizing medical criteria, established policies and procedures, Title 22, Medicare and/or Medi-Cal guidelines. This includes review of submitted medical documentation.
Determines the appropriate action regarding the service being requested for approval, modification or denial and refers to the Medical Director for review when necessary.
Initiates contact with patient, family and treating physicians as needed to obtain additional information or to introduce the role of CalAIM and case management.
Analyzes all requests with the objective of monitoring utilization of services, which includes medical appropriateness and identify potentially high cost, complex cases for high level case management intervention.\
For short-term cases, conducts a thorough and objective assessment of the member’s current physical, psychosocial and environmental status and gathers all information pertinent to the case.
Develops, implements and monitors a care plan through the interdisciplinary team process in conjunction with the individual member and family in internal and external settings across the continuum of care.
Assesses member’s status and progress routinely; if progress is static or regressive, determines reason and proactively encourages appropriate referrals to a higher level of case management or makes appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
Reports cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.
Establishes means of communication and collaboration with CalAIM providers, other team members, physicians, CBAS centers, IHSS liaisons, community agencies, health networks, skilled nursing facilities and administrators.
Prepares and maintains appropriate documentation of patient care and progress within the care plan.
Acts as an advocate in the member’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
Works collaboratively with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem-solving complex cases.
Documents case notes and rationale for all decisions in the Medical Management System (i.e., JIVA, CCMS system, Altruista Guiding Care, etc).
Conducts assessments by collecting in-depth information about a member’s situation, identifies high-risk needs, issues and resources and gathers all information pertinent to the case to write referrals for any gaps in services.
Plans and determines specific objectives, goals and actions as identified through the assessment process and makes recommendations to nursing facilities for the care of the patients.
mplements by conducting specific interventions, including referring members to outside resources and/or community agencies that will result in meeting the goals established in the care plan.
Supports implementation of the care plan through an interdisciplinary team process in conjunction with the member, family and all participants of the health care team.
Monitors established measurable goals and routinely assesses the member’s status and progress to proactively make appropriate recommendations for adjustments in the care plan, providers and/or services to promote better outcomes.
Performs utilization review of services requested for members in case management by reviewing all pertinent medical records for medical necessity, applying medical review protocols and criteria and meeting the timeframes per the Utilization Management policies and procedures.

Other Duties (5%):

Completes other projects and duties as assigned.

Required Qualifications:

Associate degree in nursing (ADN) PLUS 3 years of nursing experience with 1 year as a Clinical Nurse Reviewer required; an equivalent combination of education sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

Preferred Qualifications:

Bachelor’s degree in nursing (BSN).
Managed care experience.
Authorization review experience.
Bilingual in English and in one of Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).
Required Licensure / Certifications:
Current unrestricted Registered Nurse (RN) license to practice in the state of California required.

Knowledge & Abilities:

Work independently and exercise sound judgment.
Communicate clearly and concisely, both orally and in writing.
Work a flexible schedule; available to participate in evening and weekend events.
Organize, be analytical, problem-solve and possess project management skills.
Work in a fast-paced environment and in an efficient manner.
Manage multiple projects and identify opportunities for internal and external collaboration.
Motivate and lead multi-program teams and external committees/coalitions.
Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Physical Requirements:

Ability to read information from computer screens and printed materials.
Clear verbal communication for telephone and face-to-face interactions.
Manual dexterity for typing, writing, and prolonged sitting.
Ability to lift and move objects up to 25 pounds.

Work Environment:

Work is typically indoors and sedentary, with variable work hours and travel as needed.
Moderate noise level.

Benefits with CareNational:

Health, Dental & Vision Insurance
Weekly Pay
Referral Bonus
401(k) Matching

If you are passionate about healthcare and want to make a difference, apply today One of our recruiters will reach out to you immediately.

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#LI-NATIONAL
#LI-ONSITE

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