Medical Case Manager

About the Opportunity

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. We are hoping you will join us as a Medical Case Manager and help shape the future of healthcare where you'll be an integral part of our Case Management team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders.

Position Details

This position has been approved to be Full Telework. If telework is approved, you are required to work within the State of California only. Case Management is an advanced specialty collaborative practice responsible for providing ongoing case management services for CalOptima Health's members. The Medical Case Manager will facilitate communication and coordination among all participants of the health care team and CalOptima Health's members to ensure the services provided promote quality and cost-effective outcomes for all members. You will be responsible for providing intensive case management, which includes assessment, planning, implementation, coordination, monitoring and evaluation of the member's needs.

Responsibilities

• Care Management (85%):
  • Assesses member needs using a standardized health needs assessment or health risk assessment.
  • Performs comprehensive, disease specific, clinical assessments of all identified cases, which includes but is not limited to, assessment of: member's physical, functional, social and psychological status; member's cultural and linguistic needs; caregiver resources and available benefits.
  • Performs post-discharge assessments to identify member's post-hospital or post-emergency department discharge needs including but not limited to: member's physical, functional, social and psychological status; member's cultural and linguistic needs; caregiver resources and available benefits; follow-up provider care and ensuring scheduled appointments; durable medical equipment and supplies; community resources.
  • Develops and implements a member's specific care plan which includes prioritized Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) goals.
  • Reviews, modifies and updates care plans continuously to reflect the member's needs, at minimum, annually or upon change in condition.
  • Schedules follow-ups to assess progress towards goals and identifies barriers to meeting goals.
  • Provides regular outreach to assigned members along with members from a worklist and evaluates quality of service given to members according to department contact standards.
  • Coordinates care and services with members, members' family members/representatives and other providers, as appropriate, including community supports and Long-Term Services and Supports (LTSS).
  • Communicates with member's physicians, specialists, community agencies and vendors to ensure coordination of services.
  • Facilitates referrals to behavioral health/substance use disorder services and identifies and makes referrals to LTSS department, community supports and community resources.
  • Facilitates and participates in Interdisciplinary Team meetings as applicable.
  • Collaborates with interdepartmental staff in case resolution as needed.
  • Identifies cases needing supervisor, manager, director or medical director review or input, routes accordingly and closes cases according to procedures and guidelines in a timely manner.
  • Advocates in the member's best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
• Administrative Support (10%):
  • 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.
  • Follows CalOptima Health's protocol for documenting all case interventions.
  • Prepares and maintains appropriate documentation of patient care and progress within the care plan.
• Other (5%):
  • Completes other projects and duties as assigned.

Requirements

• Associate degree in nursing (ADN) or related field required PLUS 3 years of clinical experience and/or managed care experience required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
• Current, unrestricted Registered Nurse (RN) license to practice in the state of California required.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN) degree or related field.
• Case Management Certification (CCM).
• Bilingual in English and one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).

Knowledge & Abilities

• 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.

Physical Requirements

With or without accommodations:

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds.

Work Environment

• If located at the 500, 505 Building or a remote work location: Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. There are no harmful environmental conditions present for this job. The noise level in this work environment is usually moderate.
• If located at PACE: Work is typically indoors in a clinical setting serving the frail and elderly. There may be harmful or hazardous environmental conditions present for this job. The noise level in this work environment is usually moderate to loud.
• If located in the community: Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. Employee will occasionally work outdoors in varied temperatures. There may be harmful or hazardous environmental conditions present for this job. The noise level in this work environment is usually moderate to loud.

Pay

Pay Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615 per hour). The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.

Benefits

• Comprehensive benefits package
• CalPERS pension program and additional retirement packages
• Generous PTO program
• Quality work life balance
• Various wellness programs
• Tuition Reimbursement
• Professional development opportunities
• Career development opportunities
• Flexible scheduling
• The satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families