Overview To initiate and coordinate a multidisciplinary team approach to case management. Engages themember/member’s representative in a care plan that assists the member in meeting his/her healthand wellness goals. Collaborates, assesses, plans, facilitates, evaluates, and advocates to meet thecomprehensive medical, behavioral, and psychosocial needs of the member, while promotingquality and cost-effective outcomes.
Responsibilities
- Essential Duties and Responsibilities
- Provides case management services independently for a caseload ranging in complexityfrom basic to complex; acuity levels 1-4; performs field-based case management (acuitylevel 5) with supervision.
- Initiates and coordinates individualized care plan for assigned members, addressing bothclinical and non-clinical components, and ensuring the care plan is availableto both the member and primary care provider.
- Resolves member needs by utilizing multidisciplinary team strategies, including HealthServices Integrated Rounds Meetings.
- Ensures a smooth implementation and continuum of care via effective and frequentcommunication with providers, members, and identified health care designee.
- Elicits medical information from providers and reviews medical records, applyingclinical judgment to identify case management needs and support care coordinationactivities. Facilitates medical records retrieval through appropriate channels andestablished submission processes.
- Communicates clearly and effectively through all mediums of communication withmembers, providers, vendors, community partners, and Partnership employees.
- Coordinates referrals and authorizations for services required to improve themember’s health status.
- Maintains accurate and timely documentation, records, and case files in the PartnershipCase Management System for members in case management.
- Applies evidence-based interventions based upon member’s agreed upon goals/
- priorities
- Develops and maintains knowledge of a community based network of alternativemodes of care; aids member to connect with community-based organizations to supportand enhance wellness.
- Answers and triages department calls, and distributes department referrals withguidance, in accordance with identified department service levels.
- Collaborates and coordinates with other internal departments to identify memberssuitable for case management.
- Actively participates in essential skills training, unit and departmental assigned learning,and other departmental activities as assigned.
- Functions collaboratively in a team environment, including acting as a support andresource to other staff.
- Coordinates and participates in meetings with Partnership providers, as assigned.
- Collaborates with other departments with coordination of care needs through the courseof case management services.
- Demonstrates competence in NCQA documentation standards.
Qualifications
Education and Experience Associate’s degree in Nursing required; Bachelor’s degree in Nursing(or higher) preferred. 2 years of experience preferred, to include at leastone (1) year of case management experience and one (1) year in anacute care setting; or equivalent combination of education andexperience. General knowledge of managed care and/or experiencewith Medicaid population preferred. Special Skills, Licenses and Certifications Current and unrestricted California Registered Nurse License. ValidCalifornia driver’s license and proof of current automobile insurancecompliant with Partnership policy are required to operate a vehicle andtravel for company business. Bilingual skills in an approved thresholdlanguage is preferred. Performance Based Competencies Strong organizational, communication, critical thinking skills andattention to detail required. Ability to work within an interdisciplinarystructure and function independently in a fast-paced environment whilemanaging multiple priorities and meeting deadlines. Effectivetelephone and computer data entry skills required. Experience inmanaged care business practices and ability to access data informationusing various computer systems. Excellent English written and verbalcommunication skills required. Work Environment And Physical Demands Able to utilize multiple computer platforms simultaneously. Daily useof telephone and computer for most of the day. Standard cubicleworkstation. Must be able to lift, move, or carry objects of varying size,weighing up to 10 lbs.. All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated. HIRING RANGE: $ 106,667.05 - $ 138,667.16 IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change
