Under general supervision, the Lead Case Manager Nurse is responsible for achieving overall clinical performance goals through day to day direction of the designated clinical care team. Through coordinating operational processes and monitoring performance in a manner that ensures that HPSJ, regulatory and contractual requirements related to quality are met. Work is varied and moderately complex, and requires a limited to moderate degree of discretion and independent judgment.
Essential Functions
- In partnership with the Case Management Supervisor, leads the Case Management team and provides day to day oversight of team functions to meet all regulatory guidelines and company initiatives for Case Management cases.
- Works in collaboration with the supervisor to identify and implement consistent work processes to achieve compliance with NCQA and state standards and continuous operational readiness.
- Monitors daily workflow including; incoming referrals, case load and acuity management to meet production standards and to achieve compliance standards according to regulatory guidelines and company initiatives for CCS and Pediatric cases.
- Independently oversees and advises the correct application of methodology and outcomes monitoring and reporting for members eligible for the case management program.
- Utilizes clinical knowledge to apply evidence- based practice guidelines and criteria.
- Conducts and records both focused and standard QI audits in collaboration with supervisor.
- Tracks and trends performance, identifies root causes, and reports and recommends improvement opportunities to management, based on audit results.
- Coaches, trains, and conducts follow up for team performance improvement.
- Collaboration with the supervisor to identify, design and deliver training modules to promote improved performance and/or implement new regulatory guidelines.
- Carries caseload, as assigned by the supervisor.
- Acts as subject matter expert and participates in the training of new clinical personnel.
- Maintains the Unit’s Training Manual and Desktop Procedures (Job Aids).
Required Skills
- Produces work that is accurate and complete.
- Produces the appropriate amount of work.
- Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
- Rebounds from setbacks and adversity when facing difficult situations.
- Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
- Strong clinical skills as an RN as defined in California scope of practice guidelines.
- Strong knowledge and current NCQA standards; researches and remains current with a federal and state laws and regulations.
- Strong knowledge of federal and state laws, standards and regulations, including Medi-Cal and/or Medicare and HIPAA, in managed care organizations.
- Strong knowledge of and proficient skills in administering protocols.
- Ability to design workflow and procedures.
- Strong knowledge of audit processes, and the ability to effectively implement and maintain them.
- Ability to read and apply clinical information, practice guidelines and other complex data and information.
- Strong analytical, assessment and problem-solving skills.
- Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
- Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
- Strong oral and written communication skills with the ability to communicate with diverse individuals inside and outside of HPSJ, effectively explain complex information, do presentations, and document according to standards.
- Ability to use tact and diplomacy to diffuse emotional situations.
- Ability to commit to and facilitate an atmosphere of collaboration and team work.
- Strong customer service skills.
- Ability to develop and deliver relevant and effective training and supporting materials.
- Ability to enter data into and navigate through multiple databases.
- Intermediate skills in Word, Excel and Outlook.
- Demonstrated ability to supervise staff in a manner that maximizes employee performance and business results.
- Ability to speak and be understood in English.
- Ability to handle confidential information with appropriate discretion.
Required Experience
- Associate Degree in Nursing.
Preferred
- Bachelor’s degree in Nursing.
- Minimum two years acute clinical experience; two years experience in utilization management in health plan, medical group or IPA setting is preferred.
LICENSES, CERTIFICATIONS
Required
- Current and valid, unrestricted California state RN nursing license.
- Valid Driver Licenses with no driving restrictions.
Preferred
- Current Certified Case Manager (CCM) Preferred.