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Medical Case Manager (Ambulatory)
Department(s): Case Management
Reports to: Manager, Case Management
FLSA status: Non-Exempt
Salary Grade: L - $77,000 - $109,000
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.
• 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.
Possesses the Ability To:
• Maintain and ensure confidentiality of patient information.
• 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.
• Communicate clearly and concisely, both verbally and in writing
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Experience & Education:
• Associate Degree in Nursing (ADN) or related field required.
• Current, unrestricted Registered Nurse (RN) license to practice in the State of California required.
• 5+ years clinical experience, managed care experience required.
• Bachelor of Science in Nursing (BSN) degree or related field preferred.
• Certified Case Manager (CCM) certificate preferred.
• Bilingual in English and one of CalOptima's defined threshold languages (Spanish, Vietnamese, Arabic, Farsi, Korean, Chinese) is preferred.
• 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.
CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima 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 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.
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. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.
Job Location: Orange, California
To apply, visit https://apptrkr.com/2342685
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