Care Management Specialist II (RN or LCSW)

Salary Range

Min.$88,854.00 Mid.$115,509.00 Max.$142,166.00

About the role

L.A. Care Health Plan is an independent public agency established in 1997 to provide health coverage to low-income Los Angeles County residents. We serve more than 2 million members and aim to ensure they receive quality health care. Our mission is to provide access to quality health care for vulnerable and low-income communities.

Job Summary

The Care Management Specialist II performs essential functions of care management for identified and assigned member population, applying clinical knowledge and experience to evaluate information and determine care management intervention necessity. They manage a caseload across various programmatic levels, including those with severe acuities or care needs.

Responsibilities

• Manages a specified caseload across the entire continuum of programmatic levels, including those within NCQA scope or otherwise Complex/Catastrophic cases.
• Coordinates health care benefits, provides education, and facilitates member access to care in a timely and cost-effective manner.
• Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment.
• Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team.
• Provides direction and assistance to Care Coordinators and Community Health Workers (CHWs) regarding members' needs.
• Uses claims processing and care management software to look up member information, document contacts, and track member progress.
• Applies clinical knowledge and experience to evaluate information regarding prospective care management members referred by HRA, risk stratification, predictive modeling, provider’s utilization review vendors, members, Call Center, claims staff, HHP eligibility or other data sources to determine whether care management intervention is necessary.
• Conducts Care Management services for the most complex and vulnerable members, including engaging in member-centric communication, conducting comprehensive clinical assessments, and developing member-centric plans of care.
• Maintains assigned care management caseload for the most complex, highest-risk members, particularly those with advanced chronic conditions, co-occurring mental and/or substance abuse, and complex social issues.
• Collaborates with primary care physicians and other treating professionals as appropriate.
• Authorizes initiation of care management services and specialized program services for members and specific populations, and develops interventions designed to meet member or population desired outcomes.
• Provides comprehensive education and resources to members about accessing services, in-network use, national guidelines for care, community resources, and self-management skills and strategies.
• Employs engagement techniques to build relationships with members and their authorized representatives.
• Notifies Care Coordinators and CHWs of members' needs, including the need for special educational mailings, reminder calls, satisfaction surveys, incentives, or any additional service needs according to specific program guidelines.
• Performs field assessment and care coordination functions in community settings with members, such as at the L.A. Care Community Resource Centers, medical clinics, and member homes.
• Meets and assesses members at L.A. Care Community Resource Centers, as needed.
• Provides effective care management for Individualized Care Plan summaries and interventions during Interdisciplinary Care Team meetings based on department guidelines.
• Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care.
• Identifies member needs for and refers to appropriate internal and external programs, as appropriate.
• Encourages member and family empowerment through education and use of reliable resources.
• Maintains assigned care management caseload for the most complex, highest-risk members, particularly those with advanced chronic conditions, co-occurring mental and/or substance abuse, and complex social issues.
• Monitors and evaluates member progress, evaluating member response to interventions and refining action plan to produce desired outcomes.
• Identifies complex care management issues and discusses possible solutions with management.
• Uses claims and care management software to document interactions and interventions with members, vendors, and providers.
• Maintains case information in the member's clinical records to promote care coordination.
• Provides ongoing direction and support to internal customers regarding Care Management programs, processes, and benefit coverage.
• Responsible for staying current with best practices, identifying areas for personal growth opportunities, and working with management to develop a plan for obtaining necessary training.
• Performs other duties as assigned.

Requirements

• Minimum of 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group, or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments.
• Experience providing care management with complex/catastrophic conditions.

Skills

• Current knowledge of clinical standards of care and disease processes.
• Critical thinking skill.
• Excellent customer service skills.
• Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic, and/or psychosocial issues to determine and implement the most effective member-centered interventions.
• Ability to triage immediate member health and safety risks.
• Ability to sensitively manage member or family responses associated with high acuity cases and support effective coping.
• Strong verbal and written communications skills to consult effectively with interdisciplinary teams, coordinate care with members and their families, and other internal and external stakeholders.
• Ability to use a personal computer, and knowledge of medical information systems.
• Knowledge of and ability to comply with HIPAA compliance.
• Ability to interview, assess, and coordinate care.
• Ability to prioritize caseload.
• Knowledge of community resources.
• Knowledge of Medi-Cal and Medicare regulations.
• Ability to work as a part of a diverse team and gain consensus and resolution of problems.

Qualifications

• Required: Registered Nurse (RN); current and unrestricted California License OR Licensed Clinical Social Worker; current and unrestricted California License.
• Preferred: Certified Case Manager (CCM) Accredited Case Manager (ACM) Certification Case Management Nurse – Board Certified (CMGT-BC).

Benefits

L.A. Care offers a wide range of benefits including paid time off (PTO), tuition reimbursement, retirement plans, medical, dental, and vision coverage, wellness program, volunteer time off (VTO), and more.