The Medical Case Manager (Long Term Care) (LTC) is part of an advanced
specialty collaborative practice, responsible for case management, care
coordination and utilization management of the assigned population
(Members residing in LTC Nursing Facilities under custodial care)
including members in the OneCare Connect or OneCare Programs, Medi-Cal
only members or members living in the Intermediate Care Facilities under
Regional Center guidelines. The incumbent performs utilization
functions, provides coordination of care, and provides ongoing case
management services for CalOptima members discharging from Long Term
Care (LTC) facilities. Discharge planning may include services for
Community Based Adult Services (CBAS) and/or In-Home Support Services
(IHSS) post-discharge. The incumbent reviews and determines medical
eligibility based on approved criteria/guidelines, NCQA standards,
Medicare and Medi-Cal guidelines, and facilitates communication and
coordination among all participants of the health care team and the
member to ensure services are provided to promote quality,
cost-effective outcomes. The incumbent provides intensive case
management in a collaborative process that includes assessment,
planning, implementation, coordination, monitoring and evaluation of the
member’s needs. The incumbent is the subject matter expert and acts as a
liaison to Orange County based community agencies, CBAS centers, IHSS
Liaisons, skilled nursing facilities, and to members and providers.
POSITION RESPONSIBILITIES:
- Apply case management/nursing processes that include assessment,
care planning collaboration, advocacy, implementation/intervention,
monitoring and evaluation of a member’s status.
- Perform and/or review clinical assessments by using CalOptima and
DHCS approved standardized tools such as Pre-Admission Screening and
Resident Review (PASSAR), Minimum Data Set (MDS), CBAS Eligibility
Determination Tool (CEDT), Health Risk Assessment (HRA), Individual
Plans of Care, etc.
- Receive reviews, verify and process requests for referrals,
diagnostic testing, inpatient admissions, outpatient
procedures/testing, emergency room notification, home health care
services, and durable medical equipment and supplies via telephone
or fax.
- Complete all documentation accurately and appropriately for data
entry into the utilization management system at the time of the
telephone call or fax to include any authorization updates.
- Review and evaluate proposed services utilizing medical criteria,
established policies and procedures, Title 22, Medicare and/or
Medi-Cal guidelines. This includes review of submitted medical
documentation and/or photographs.
- Determine the appropriate action with regard to the service being
requested for approval, modification or denial, and refer to the
Medical Director for review when necessary.
- Initiate contact with patient, family, and treating physicians as
needed to obtain additional information or to introduce the role of
case management.
- Analyze 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, conduct a thorough and objective assessment of
the member’s current physical, psychosocial and environmental
status, and gather all information pertinent to the case. Develop,
implement and monitor 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.
- Routinely assess member’s status and progress; if progress is static
or regressive, determine reason and proactively encourage
appropriate referrals to a higher level of case management or make
appropriate adjustments in the care plan, providers and/or services
to promote better outcomes.
- Report cost analysis, quality of care and/or quality of life
improvements as measured against the case management goals.
- Establish means of communication and collaboration with other team
members, physicians, CBAS centers, IHSS Liaisons, community
agencies, health networks, skilled nursing facilities,
and administrators.
- Prepare and maintain appropriate documentation of patient care and
progress within the care plan.
- Act 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.
- Work collaboratively with staff members from various disciplines
involved in patient care with an emphasis on interpreting and
problem solving complex cases.
- Document case notes and rationale for all decisions in the Medical
Management System (i.e. CCMS system, Altruista Guiding Care, etc).
- Assessment collect in-depth information about a member’s situation,
identify high-risk needs, issues, resources and gather all
information pertinent to the case in order to develop a
comprehensive care plan to meet those needs.
- Planning determine specific objectives, goals and actions as
identified through the assessment process. The comprehensive care
plan will be action oriented, time specific and be applied across a
continuum of care for the individual member.
- Implementation- conduct specific interventions, including referring
members to outside resources and/or community agencies that will
result in meeting the goals established in the care plan.
- Implement the care plan through an interdisciplinary team process in
conjunction with the member, family and all participants of the
health care team.
- Monitoring established measurable goals and routinely assesses the
member’s status and progress in order to proactively make
appropriate adjustments in the care plan, providers and/or services
to promote better outcomes.
- May perform utilization review of services requested for members
that are 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.
- Assist the LTSS Manager in identifying areas of staff training
needed and in maintaining current date resources.
- Maintain confidentiality of the member’s medical information.
- Other projects and duties as assigned.
Required Skills
- Evaluate the quality of necessary medical services, and be able to
acquire and analyze the cost of care.
- Assist in the formulation of medical case management policies and
procedures; understand and interpret policies, procedures
and regulations.
- Develop and maintain effective working relationships with all levels
of staff, other programs, agencies, and the general public.
- Communicate effectively at all organizational levels and in
situations requiring instructing, persuading, negotiating,
consulting, and advising.
- Assess resource utilization, cost management and
negotiate effectively.
- Perform utilization management and case management functions.
- Solve problems and multi-task in a fast-paced environment while
meeting deadlines.
- Provide coaching and training to providers including CBAS centers,
home health agencies, and/or providers, etc.
- Interpret and apply established clinical criteria, Title 22,
Medicare and Medi-Cal guidelines.
- Benefits interpretation and administration.
- Principles and practices of managed health care.
- Perform clinical assessments by applying case
management/nursing processes.
- Prepare clear, comprehensive written and verbal reports
and materials.
- Effectively utilize computer and appropriate software and interact
as needed with CalOptima Information Services.
Required Experience
EXPERIENCE & EDUCATION:
- Current and extensive knowledge of the NCQA, Title 22, Medi-Cal,
Medicare and CalOptima programs is preferred.
- Current, unrestricted RN license to practice in the State of
California is required.
- Degree in Nursing or license that permits independent practice
without the supervision of another licensed professional.
- 3+ years of clinical experience with the health needs of the
population served, and extensive experience at an increasingly
responsible professional level that is directly related to the
knowledge and abilities listed is required.
- Active CCM certification is preferred.
- Valid driver’s license and vehicle, or other approved means of
transportation, an acceptable driving record, and current auto
insurance will be required for work away from the primary office
approximately 95% of the time.
KNOWLEDGE OF:
- Guidelines and regulations relevant to case management and
utilization management.
- Understand confidentiality and the legal and ethical issues
pertaining to case management.
- ICD-10 and CPT coding, requirements for prior approval.
- Available community resources.
- Effective charting practices and guidelines.
- Available medical treatments and resources.
- Principles and practices of health care, health care systems, and
medical administration.
- Personal computers, keyboarding, and appropriate software to produce
correspondence, charts, spreadsheets, and/or other information
applicable to the position assignment.
- Hospice, Long term services and supports such as nursing facility
admission criteria, Community Adult Based Services (CBAS), In-Home
Supportive Services (IHSS), and/or Multipurpose Senior Services
Program (MSSP) benefits.
Grade: N