DEPARTMENT(S): Case Management REPORTS TO: Manager, Case Management FLSA STATUS: Non-Exempt SARALRY GRADE: L - $37.02 - $57.64 ($77,000 - $119,900)

ABOUT CALOPTIMA HEALTH

CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health.  We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring.  CalOptima Health has been recognized as one of Orange County’s best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! 

ABOUT THE POSITION

Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for CalOptima Health’s members. The Medical Case Manager facilitates 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. The incumbent will be responsible for providing intensive case management, which includes assessment, planning, implementation, coordination, monitoring and evaluation, of the member’s needs.

POSITION RESPONSIBILITIES:

• 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.
• 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,
  • Caregiver resources and available benefits.
• Develops and implements a Member’s specific care plan which includes prioritized goals.
• Schedules follow-up to assess progress towards goals and identifies barriers to meeting goals.
• Communicates with Member’s physicians, specialists, community agencies and vendors to ensure coordination of services.
• Follows CalOptima Health’s protocol for documenting all case interventions.
  • Facilitates Interdisciplinary team meetings as applicable.
• Collaborates with interdepartmental staff in case resolution as needed.
• Identifies cases needing manager, director or medical director review or input, routes accordingly and closes cases according to procedures and guidelines in a timely manner.
• Prepares and maintains appropriate documentation of patient care and progress within the care plan.
• Advocates in the member’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
• Other projects and duties as assigned.

EXPERIENCE & EDUCATION:

• Associate’s degree in Nursing (ADN) or related field required.
• Current unrestricted Registered Nurse (RN) license to practice in the State of California required.
• 5 years clinical experience required; 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 is also qualifying.

PREFERRED QUALIFICATIONS:

• Bachelor of Science in Nursing (BSN) degree or related field.
• Certified Case Manager (CCM) certificate.
• Bilingual in English and one of CalOptima Health’s defined threshold languages (Spanish, Vietnamese, Arabic, Farsi, Korean, Chinese).

ABOUT OUR BENEFITS & WELLNESS OPTIONS:

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

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Required Skills Required Experience