Medical Case Manager, RN - Impresiv Health
Orange, CA 92868
About the Job
Title: Medical Case Manager RN - LTSS
Duration: up to 6 months
Compensation: $43.66-$69.86/hour
Description: 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 Based Adult 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.
What You Will Do:
You Will Be Successful If:
What You Will Bring:
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!
Duration: up to 6 months
Compensation: $43.66-$69.86/hour
Description: 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 Based Adult 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.
What You Will Do:
- 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, client 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.
You Will Be Successful If:
- Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
- Work independently and exercise sound judgment.
- Communicate clearly and concisely, both orally and in writing.
- Work a flexible schedule; available to participate in evening and weekend events.
- Organize, be analytical, problem-solve and possess project management skills.
- Work in a fast-paced environment and in an efficient manner.
- Manage multiple projects and identify opportunities for internal and external collaboration.
- Motivate and lead multi-program teams and external committees/coalitions.
- 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.
What You Will Bring:
- Associate's degree in nursing required, Bachelor's degree in nursing (BSN) preferred.
- 3 years of clinical experience with the health needs of the population served required.
- Current, unrestricted Registered Nurse (RN) license to practice in the state of California required.
- 2 years of experience in Long Term Care, Community Health, Managed Care Medi-Cal, Medicare programs preferred.
- Active Commission for Case Manager (CCM) certification preferred.
- Bilingual in English and in one of the following defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese) preferred.
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!
Source : Impresiv Health
