THE OVERVIEW:
Under general supervision, conducts case management activities on assigned members where analysis, synthesis and evaluation of data and information are required. In addition, this position is responsible for developing, implementing and evaluating individual care plans to ensure that care is rendered at the most appropriate level, for the requisite length of time, and in compliance with HPSJ, regulatory and contractual requirements. Work is varied and complex and requires a moderate amount of discretion and independent judgement.
Your Day To Day:
- Assesses and evaluates members care needs.
- Educates member on HPSJ services and the case management process.
- Develops complex care plans in partnership with member and member’s PCP.
- Collaborates with member, his/her family, and external and internal resources to ensure understanding of and compliance with care plans.
- Escalates high risk medical issues to Medical Director for review; approves or denies services as directed.
- Monitors and evaluates progress at appropriate intervals; conducts appropriate interventions.
- Supports and advises members on self-advocacy efforts.
- Documents activities in appropriate HPSJ system(s) according to standards.
- Tracks data as required; compiles data for, produces and submits routine reports.
- Reviews care plans developed by LVN Case Managers and Entry Level Case Managers.
Required Skills
Your Skills:
REQUIRED:
- Produces work that is accurate and complete.
- Produces the appropriate amount of work.
- Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
- Rebounds from setbacks and adversity when facing difficult situations.
- Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
- Strong clinical skills as defined in California scope of practice guidelines for RN’s.
- In-depth knowledge of and proficient skills in administering protocols for utilization management, discharge planning and/or case management.
- In-depth knowledge of health care delivery systems as they apply to case management.
- Ability to read, interpret and apply clinical information, practice guidelines and other complex data and information.
- Strong skills in assessment and analysis.
- Strong problem solving skills.
- Basic negotiation skills.
- Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
- Strong oral and written communication skills, with the ability to communicate professionally to diverse individuals inside and outside of HPSJ, effectively explain complex information, and document according to standards.
- Ability to use tact and diplomacy to diffuse emotional situations.
- Ability to work independently and as part of a team.
- Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
- Strong customer service skills.
- Basic skills in Word and Excel.
- Ability to enter data into and navigate through multiple databases.
- Ability to speak and be understood in English.
- May require proficiency in one of HPSJ’s threshold languages (as defined by HPSJ’s Cultural and Linguistic Program).
- Ability to handle confidential information with appropriate discretion.
REQUIRED WITHIN ONE YEAR OF HIRE:
- In-depth knowledge of government sponsored programs and regulations as they apply to case management.
- In-depth knowledge of managed care principles, practices and regulatory requirements as they apply to case management.
Required Experience
What You Bring:
REQUIRED:
- Graduation from an accredited nursing school.
- At least three years clinical experience as an RN in a hospital or clinic.
- At least three years performing case management, utilization management or discharge planning.
PREFERRED:
- Experience as a clinician in a managed care setting.
- Experience working with Medi-Cal and/or Medicare populations.
- Certified Case Manager Designation.
LICENSURE, CERTIFICATION, REGISTRATION:
- Unrestricted California Registered Nurse license.
- Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.