Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for CalOptima members. The Case Manager facilitates communication and coordination among all participants of the health care team and the member to ensure that the services are provided to promote quality cost-effective outcomes.
The Ambulatory Case Manager provides intensive case management in a process that includes assessment, planning, implementation, coordination, monitoring and evaluation of the member’s needs.
POSITION RESPONSIBILITIES:
Performs comprehensive, disease specific, clinical assessment of all identified cases which includes but is not limited to:
- Assessment of member’s physical, functional, social determinants of health, and psychological status.
- Assessment of member’s cultural and linguistic needs.
- Assessment of caregiver resources and available benefits.
Offers services at the location most convenient to the member within HHP and MCP guidelines.
Develops and implements a member specific Health Action Plan (HAP) care plan which includes prioritized goals.
Connects HHP member to social services and supports as needed.
Advocates on behalf of members with health care professionals.
Uses motivational interviewing and trauma-informed care practices in engaging and working with members.
Works with member and providers to facilitate smooth transitions of care.
Arranges accompaniment to office visits as appropriate.
Provides health promotion and self-management training.
Facilitates access to transportation.
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’s protocol for documenting all case interventions.
Facilitates healthcare team meetings as indicated via telephone or onsite.
Works collaboratively with interdepartmental staff, as needed, in case resolution.
Identifies cases needing Manager, Director or Medical Director review or input and routes accordingly.
Closes cases according to defined case closure procedure in a timely manner, and in accordance with established guidelines.
Prepares and maintains appropriate documentation of patient care and progress within the medical management system.
Acts as an advocate in the client’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.
Required Skills
- Maintain and ensure confidentiality of patient information in accordance with HIPAA and community standards of practice.
- Develop rapport and establish and maintain effective interpersonal relationships with internal and external contacts at all levels.
- Communicate clearly and concisely, both verbally and in writing, with individuals from varying clinical, nonclinical and diverse backgrounds.
- Effectively interview members to determine strengths, problems, functional status, goals and need for specific services/resources using motivational interviewing and trauma informed care practices to establish prioritized goals.
- Develop a Health Action Plan (HAP) that addresses member’s physical, psychosocial, functional, strengths/barriers, social determinants of health, and mental health needs.
- Work with the healthcare team, provider staff and community-based organizations to expedite the resolution of member concerns.
- Remain knowledgeable of Medi-Cal and Medicare benefit sets, available community-based resources, and programs.
- Maintain accurate records and documentation.
- Proactively utilize all available resources for decision making.
- Advocate on behalf of the individual to assure quality of care and attainment of appropriate goals.
- Develop and maintain effective working relationships with all levels of staff, other programs, agencies, and the population served.
- Access and interpret reports and data.
- Perform tasks independently and prioritize workload.
- Utilize clinical judgment, independent analysis, and evidenced base clinical guidelines in decision making.
- Utilize and access computer and appropriate software (e.g. Microsoft Office; Word, Excel, PowerPoint) and job-specific applications to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Required Experience
EXPERIENCE & EDUCATION:
- Registered Nurse with an Associate (ADN) required and/or Bachelor (BSN) degree in nursing preferred.
- Active and unrestricted California Registered Nursing license required.
- 5 years clinical experience, managed care experience preferred.
- CCM certificate preferred.
- Bilingual in English and one of CalOptima’s defined threshold languages is preferred.
- Valid California driver’s license and vehicle, or other means of transportation, and an acceptable driving record will be required for work away from the primary office 50% of the time or more.
KNOWLEDGE OF:
- Guidelines and regulations relevant to case management and utilization management.
- Understand confidentiality and the legal and ethical issues pertaining to case management.
- National Committee for Quality Assurance (NCQA) PHM Standards; Complex Case Management preferred.
- 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.
Grade: N
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