Department(s): Long Term Care
Reports to: Supervisor, Long Term Support Services
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 , February 29, 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

Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you’re looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health!

About the Position

The Medical Case Manager (LTSS) is part of an advanced specialty collaborative practice, responsible for case management, care coordination, authorization and utilization management of the assigned population of focus (Community Adult Based Services (CBAS), CalAIM, complex discharge and long term care (LTC) members residing in nursing facilities under custodial care) including members in the OneCare Programs, Medi-Cal only members or members living in the intermediate care facilities under regional center guidelines. The incumbent will perform utilization functions and authorizations, provide coordination of care and ongoing case management services for CalOptima Health members discharging from LTC facilities. Discharge planning may include services for CalAIM, LTC and CBAS. The incumbent will review and determine medical eligibility based on approved criteria/guidelines, National Committee for Quality Assurance (NCQA) standards, Medicare, Medi-Cal and CDA guidelines and will facilitate 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 will provide intensive case management in a collaborative process that includes assessment, planning, implementation, coordination, monitoring and evaluation of the member’s needs. The incumbent will be the subject matter expert and acts as a liaison to Orange County based community agencies, CalAIM program and providers, CBAS centers, In-Home Support Services (IHSS) liaisons, skilled nursing facilities, members and providers.

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.
• Applies utilization management, authorizations and case management/nursing processes that include assessment, care planning collaboration, advocacy, implementation/intervention, monitoring and evaluation of a member’s status.
• Performs and/or reviews clinical assessments by using CalAIM, CalOptima Health and DHCS approved standardized tools such as Pre-Admission Screening and Resident Review (PASRR), Minimum Data Set (MDS), CBAS Eligibility Determination Tool (CEDT), Health Risk Assessment (HRA), Individual Plans of Care, etc.
• Participates in hospital rounds.
• Collaborates with hospitals on complex discharges.
• Communicates timely with CalAIM providers and members to coordinate and initiate Community Support (CS) services and (ECM) Enhanced Case Management.
• Completes all documentation accurately and appropriately for data entry into the utilization management or care management system at the time of the telephone call or fax to include any authorization updates.
• Reviews and evaluates proposed services utilizing medical criteria, established policies and procedures, Title 22, Medicare and/or Medi-Cal guidelines. This includes review of submitted medical documentation.
• Determines the appropriate action regarding the service being requested for approval, modification or denial and refers to the Medical Director for review when necessary.
• Initiates contact with patient, family and treating physicians as needed to obtain additional information or to introduce the role of CalAIM and case management.
• Analyzes 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, conducts a thorough and objective assessment of the member’s current physical, psychosocial and environmental status and gathers all information pertinent to the case.
• Develops, implements and monitors 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.
• Assesses member’s status and progress routinely; if progress is static or regressive, determines reason and proactively encourages appropriate referrals to a higher level of case management or makes appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
• Reports cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.
• Establishes means of communication and collaboration with CalAIM providers, other team members, physicians, CBAS centers, IHSS liaisons, community agencies, health networks, skilled nursing facilities and administrators.
• Prepares and maintains appropriate documentation of patient care and progress within the care plan.
• Acts 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.
• Works collaboratively with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem-solving complex cases.
• Documents case notes and rationale for all decisions in the Medical Management System (i.e., JIVA, CCMS system, Altruista Guiding Care, etc).
• Conducts assessments by collecting in-depth information about a member’s situation, identifies high-risk needs, issues and resources and gathers all information pertinent to the case to write referrals for any gaps in services.
• Plans and determines specific objectives, goals and actions as identified through the assessment process and makes recommendations to nursing facilities for the care of the patients.
• Implements by conducting specific interventions, including referring members to outside resources and/or community agencies that will result in meeting the goals established in the care plan.
• Supports implementation of the care plan through an interdisciplinary team process in conjunction with the member, family and all participants of the health care team.
• Monitors established measurable goals and routinely assesses the member’s status and progress to proactively make appropriate recommendations for adjustments in the care plan, providers and/or services to promote better outcomes.
• Performs utilization review of services requested for members 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.
• Assists the Manager, Long-Term Support Services in identifying areas of needed staff training and in maintaining current data resources.
• Maintains confidentiality of the member’s medical information.
• Completes other projects and duties as assigned.

Experience & Education:

• Associate degree in nursing (ADN) required.
• Current, unrestricted Registered Nurse (RN) license to practice in the state of California required.
• 3 years of clinical experience with the health needs of the population served required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
• A 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 50% of the time.

Preferred Qualifications:

• Bachelor’s degree in nursing (BSN).
• 2 years of experience in Long Term Care, Community Health, Managed Care Medi-Cal, Medicare programs.
• Active Commission for Case Manager (CCM) certification.
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

Physical Demands and 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 need to move about the organization. Employee is required to participate in provider workshops, CME events and conferences. Employee must be able to communicate, particularly for regular phone use, in meetings and face-to-face interaction. Employee must have means of transportation for offsite travel to nursing facilities approximately 95% of the time.

• Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. Off-site locations are equivalent to a typical physician’s office, hospital, or other ancillary provider.

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 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.

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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

Essential Functions

• Estimate, including assisting with quantity take-offs, subcontractor list management and subcontractor contacts, research on various systems and products, studies and comparisons, document management, and keeping accurate records.
• Ensure that the estimating process runs smoothly and efficiently, and client expectations are exceeded throughout the duration of the project(s).
• Prepare quantity take-offs and apply unit pricing for material and labor to establish a value for the work.
• Prepare qualifications and assumptions for the estimate.
• Prepare cost comparisons/reconcile with previous estimates.