Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for CalOptima members. The Medical 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 and cost-effective outcomes.
This position will be responsible for providing intensive case management that includes assessment, planning, implementation, coordination, monitoring and evaluation of the member’s needs.
POSITION RESPONSIBILITIES:
- 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’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.
Required Skills
- Maintain and ensure confidentiality of patient information.
- Demonstrate excellent oral and written communication skills.
- Interview members to determine the client’s strengths, problems prognosis, functional status, goals and need for specific services/resources, and to establish prioritized goal.
- Develop a plan, when indicated through multi-disciplinary collaboration which identifies options and 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.
- Utilize and access computer programs, both Microsoft Office applications (e.g. 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:
- Associate Degree in Nursing (ADN) required, Bachelor of Science in Nursing (BSN) degree preferred.
- Active and unrestricted California registered nursing license required.
- 5 years clinical experience, managed care experience required.
- CCM certificate preferred.
- Bilingual in English and one of CalOptima’s defined threshold languages is preferred.
KNOWLEDGE OF:
- Guidelines and regulations relevant to case management and utilization management.
- Confidentiality and the legal and ethical issues pertaining to case management.
- National Committee for Quality Assurance (NCQA) Standards; Complex Case Management preferred.
- Community resources.
- 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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