Enhanced Care Management Clinical Specialist II

Job Summary

The Enhanced Care Management (ECM) Clinical Specialist II is responsible for overseeing ECM network activities, providing feedback and guidance to ECM Providers, conducting assessments and plans reviews, and assisting with case escalations.

Duties

• Conduct regular monitoring and coaching with Providers to review aggregate progress and individual ECM member cases.
• Use various methods to monitor Provider performance related to clinical and service requirements.
• Provide guidance on best practices to ECM providers.
• Conduct a monthly random sample review of Assessments and Care Plans to identify gaps and provide coaching and feedback.
• Organize and perform file review process, ensuring compliance and accuracy of documentation.
• Train, educate, and consult Providers as needed.
• Collaborate with ECM staff to develop training materials and capacity building activities.
• Aid ECM Providers with case escalations requiring additional assistance from L.A. Care.
• Coordinate member care with internal L.A. Care departments and external providers.
• Identify and implement improvements to ECM quality, effectiveness, and efficiency.
• Communicate barriers to supervisors as needed.

Education Required

Minimum 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.

Education Preferred

Previous care management experience to include auditing/oversight/performance management experience.

Skills

• Knowledge of clinical standards of care and disease processes, and community resources.
• Excellent verbal and written communication skills; interpersonal skills.
• Ability to clinically analyze complex cases involving physical health, behavioral health, complex/catastrophic, and psychosocial issues.
• Proficiency in Microsoft Office applications.
• Maintain confidentiality in compliance with HIPAA requirements.
• Solve complex issues and identify creative solutions with external agencies.
• Excellent project management skills.
• Working knowledge of Medi-Cal and Medicare regulations.

Preferred

• Bilingual in one of LA Care Health Plan’s threshold languages (English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese).
• Certification in Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), Utilization Management or Compliance.

Licenses/Certifications Required

N/A

Licenses/Certifications Preferred

N/A

Required Training

N/A

Physical Requirements

N/A

Additional Information

L.A. Care offers a wide range of benefits including:

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retail Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)