Case Manager, Ambulatory – CA. Licensure Required Hybrid (Remote Considered) - Multiple Positions

Essential Responsibilities

• Identify members appropriate for case management based on clinical indicators, referrals, utilization patterns, and health-related concerns.
• Conduct comprehensive assessments of members’ physical, psychosocial, behavioral, and environmental needs and barriers.
• Develop individualized care plans aligned with member goals, provider recommendations, and established standards of practice.
• Implement and coordinate interventions to address barriers, enhance access, and support successful goal achievement in collaboration with physicians, caregivers, and other providers.
• Document assessments, interventions, care plans, progress notes, and member interactions within the case management system according to policy and regulatory criteria.
• Provide structured case management services for ambulatory and outpatient populations, including those with chronic or complex conditions.
• Coordinate care across primary care, specialty care, behavioral health, pharmacy, and community resources to ensure cohesive outpatient support.
• Facilitate timely follow-up after emergency department visits, urgent care visits, or hospital discharges to ensure continuity of care.
• Reinforce treatment plans, promote medication adherence, and support self-management for chronic disease populations (e.g., diabetes, COPD, CHF).
• Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory, and accreditation standards.
• Ensure compliance with department procedures, turnaround times, and documentation standards.
• Support interdisciplinary care processes to promote optimal resource utilization and quality outcomes.
• Maintain and update community resource databases and internal referral pathways.
• Utilize reporting tools and internal systems to identify trends, monitor resource utilization, and support quality improvement initiatives.
• Refer members to appropriate departments such as Health Education, Quality Management, Contracting, Provider Services, and others as needed.
• Issue member communications in accordance with department policies.
• Support the Medical Management Team, including Authorization Review, Clinical Initiatives, and Provider Education functions.
• Participate in internal and external meetings, training, and educational programs to maintain and enhance case management competencies.

Required Experience

• Minimum 5 years of experience required, including at least 3 years of clinical nursing experience in areas such as medical-surgical, critical care, home health, or skilled nursing.
• At least 2 years of experience in case management, utilization management, discharge planning, or quality improvement in a managed care setting.
• Experience with managed care delivery, including IPA networks and Medicare.
• Strong organizational skills with ability to meet both expected and unexpected time frames.
• Excellent verbal and written communication skills.
• Proficiency in Microsoft Outlook, Teams, and electronic charting systems.
• Able to navigate multiple platforms and document while engaging with members.
• Able to coordinate effectively with members, providers, office staff, health plans, internal departments, community resources, and peers.
• Able to work independently with self-initiative and discipline.
• Knowledge of ICD-10 and CPT coding.
• Working knowledge of personal computers.

Required Education

• Unrestricted California Registered Nurse licensure: certification in case management required.