We are seeking a Registered Nurse (Case Manager - Patient Care) to join our team! You will be responsible for the assessment, diagnosis, and treatment of assigned patients.
Department(s): Long Term Care
Reports to: Supervisor, Long Term Support Services
The Medical Case Manager (Long Term Care) (LTC) is part of an advanced specialty collaborative practice, responsible for case management, care coordination and utilization management of the assigned population (Members residing in LTC Nursing Facilities under custodial care) including members in the OneCare Connect or OneCare Programs, Medi-Cal only members or members living in the Intermediate Care Facilities under Regional Center guidelines. The incumbent performs utilization functions, provides coordination of care, and provides ongoing case management services for Company members discharging from Long Term Care (LTC) facilities. Discharge planning may include services for Community Based Adult Services (CBAS) and/or In-Home Support Services (IHSS) post-discharge. The incumbent reviews and determines medical eligibility based on approved criteria/guidelines, NCQA standards, Medicare and Medi-Cal guidelines, and facilitates 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 provides intensive case management in a collaborative process that includes assessment, planning, implementation, coordination, monitoring and evaluation of the member's needs. The incumbent is the subject matter expert and acts as a liaison to Orange County based community agencies, CBAS centers, IHSS Liaisons, skilled nursing facilities, and to members and providers.
Experience & Education:
- Current and extensive knowledge of the NCQA, Title 22, Medi-Cal, Medicare and Company programs is preferred.
- Current, unrestricted RN license to practice in the State of California is required.
- Degree in Nursing or license that permits independent practice without the supervision of another licensed professional.
- 3+ years of clinical experience with the health needs of the population served, and extensive experience at an increasingly responsible professional level that is directly related to the knowledge and abilities listed is required.
- Active CCM certification is preferred.
- 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 95% of the time.
- Bilingual in English and one of Company's defined threshold languages is preferred.
Posses the Ability to:
- Evaluate the quality of necessary medical services and be able to acquire and analyze the cost of care.
- Assist in the formulation of medical case management policies and procedures; understand and interpret policies, procedures and regulations.
- Develop and maintain effective working relationships with all levels of staff, other programs, agencies, and the general public.
- Communicate effectively at all organizational levels and in situations requiring instructing, persuading, negotiating, consulting, and advising.
- Assess resource utilization, cost management and negotiate effectively.
- Perform utilization management and case management functions.
- Solve problems and multi-task in a fast-paced environment while meeting deadlines.
- Provide coaching and training to providers including CBAS centers, home health agencies, and/or providers, etc.
- Interpret and apply established clinical criteria, Title 22, Medicare and Medi-Cal guidelines.
- Benefits interpretation and administration.
- Principles and practices of managed health care.
- Perform clinical assessments by applying case management/nursing processes.
- Prepare clear, comprehensive written and verbal reports and materials.
- Effectively utilize computer and appropriate software and interact as needed with Company Information Services