Department(s): Multipurpose Senior Services Program (MSSP)
Reports to: Supervisor MSSP
FLSA status: Non-Exempt
Salary Grade: L - $77,000 - $127,094

Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on ** Thursday, November 9, 2023 at 11:59 PM. ** **Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. **

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

The Medical Case Manager (Multipurpose Senior Services Program) will facilitate communication and coordination among the health care team to ensure services are provided to promote quality cost-effective outcomes for the member. The incumbent will provide case management interventions on behalf of older adult members living in the community with significant medical or caregiving deficits and at risk of further deterioration and/or institutionalization. The incumbent will ensure the medical appropriateness, quality and cost-effectiveness of proposed hospital/medical/surgical services within established criteria. The incumbent will evaluate each member as a total person and identify the functional and health limitations impeding safe independent living.

Duties & 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.
• Conducts in-field, virtual or telephonic assessments of each member’s current status including physical, psychosocial and environmental conditions.
• Navigates the sensitivities of completing care management work in the private residences of members.
• Builds and maintains rapport with members from diverse backgrounds to foster effective care management relationships that support the member’s coping with complex medical, behavioral and social needs.
• Gathers and reviews all information pertinent to each member’s case, including medical documentation covering medical, health and rehabilitation concerns. Records the information and clinical impressions.
• Clinically certifies level of care determinations per the California Code of Regulations (CCR), Title 22 Sections 51334 and 51335, for each eligible applicant for whom there are reasonable indications that MSSP services are required and justified.
• Continuously assesses and communicates each member’s status and progress through their participation in the program. If progress becomes static or regressive, determines cause and proactively makes appropriate adjustments in the care plan, providers and services to promote better outcomes.
• Identifies and responds to member crisis situations by promptly prioritizing and implementing appropriate interventions.
• Initiates and maintains appropriate contact with each member’s family members, treating physicians and other health care professionals to coordinate relevant information that support the member’s functioning and coping in the community.
• Develops, implements and updates each member’s individualized care plan through the interdisciplinary team (IDT) process in conjunction with the member and family, the supervising care manager and the MSSP social worker across the full continuum of care.
• Collaborates with professionals across various disciplines involved in the member’s care, including those in community agencies, with an emphasis on interpreting and problem-solving the complex barriers to the member’s preferred care plan goals.
• Tracks each member’s quality of care and quality of life improvements, as measured against the established care plan goals.
• Advocates in the member’s best interest regarding the necessary benefit coverage, treatment alternatives and access to care.
• Completes other projects and duties as assigned.

Experience & Education:

• Associate’s degree in Nursing (ADN) required.
• Current, unrestricted Registered Nurse (RN) license to practice in the State of California required.
• 5 years of clinical experience working with the health needs of the population served required. Preferably 2 years of experience in public health with older adults.
• 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.
• 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 50% of the time or more.

Preferred Qualifications:

• Bachelor’s degree in Nursing (BSN).
• Case Management Certification (CCM).
• Public Health Nurse (PHN) certification.
• Experience in home health, hospice or skilled nursing facility and Level of Care Certification process experience.
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

Physical Demands & Work Environment:

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Physical demands: While performing duties of the job, employee may be required to move about the organization. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must be able to lift and carry up to 25 pounds to transport laptop, peripherals and other collateral material. Employee must be able to communicate, particularly for regular phone use, in meetings and face-to-face interaction. Employee must have means of transportation to and from multiple locations during a workday.

• Work environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. Employee will have one-on-one contact with other employees where hearing and listening is paramount. Off-site visit environment is equivalent to a client’s home.

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 Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.

CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health 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 Health 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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If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

Required Skills

Required Experience

Minimum Education: Graduate from an approved school of Nursing.

Required Licenses: Licensed Practical Nurses
Licensed by the State of Kentucky.