Primary Purpose:

To provide support and facilitate care for members who require case management. To work collaboratively with the Health Plan and Hospital Case Management Departments to facilitate services. To collaborate with the treating physician and IPA Medical Director in reviewing and deciding on the provision of appropriate health care and service requests. Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates an individual’s health needs through communication and available resources to promote quality and cost-effective outcomes. If applicable, the CM will coordinate care for Cal Medi-Connect program members to ensure that all aspects of the CMC program description are implemented and followed. All Medicare and Medi-Cal services will be coordinated and monitored, including CCS, IHSS, CBAS, and BH. The case manager is a licensed nurse (RN or LVN). A care manager can be a licensed social worker (MSW) or a licensed nurse (RN or LVN).

Principal Duties and Responsibilities (* = essential functions):

• To utilize the Case Management functions: assessor, planner, facilitator, advocate.
• To facilitate services at the appropriate Health Plan center of excellence.
• To utilize the most cost-effective case rates and contracts.
• Review and process clinical information in accordance with regulatory mandates to support patient healthcare and services across the continuum of care.
• To perform catastrophic case management as appropriate to the patient’s medical condition and healthcare needs, utilizing the standards of practice for Case Management.
• To interface professionally and courteously with all internal staff and external customers to ensure appropriate exchange of information.
• Prepare for and participate in onsite health plan audits as required.
• To actively participate in Utilization Management Committees regarding Case Presentations and problem-solving.
• To participate in the development of Case Management Policies and Procedures.
• To actively participate in the discharge planning process.
• To monitor and participate in the SNP/Duals program.
• To monitor and participate in the CMC program.
• To ensure all members are living in the least restrictive environment.
• To follow the UM/QI/CM/SNP/CMC program descriptions.
• Assigned to On-Call after-hours Customer Service Care.
• To perform other duties as assigned.

Job Specifications (KSAs):

• Requires extensive and specialized knowledge of utilization and case management processes, generally acquired through 2-3 years or more of experience as a case manager in a Managed Care Environment, or through successful completion of a nursing program.
• Requires prior Case Management experience, preferably with catastrophic cases.
• Requires an active RN or LVN license in the state of employment.
• Requires clinical expertise, generally acquired through 3 to 5 years of acute nursing practice.
• Requires excellent written and verbal communication skills.
• Requires computer experience, particularly with Microsoft Word and Excel, familiarity with Cozeva (a plus), and the ability to learn new software applications quickly.
• Requires problem-solving and critical thinking skills.
• Requires professional demeanor and the ability to contribute to a positive work environment.
• Requires knowledge of regulatory standards such as Medicare, Title XXII, and Medi-Cal.
• Requires extensive knowledge of health plan guidelines.

Position Performance Criteria:

1. Demonstrates proficiency in UM and Case Management including but not limited to:
• Catastrophic Case Management
• Transplant Management
• Referral review
• Out-of-network management
• Denial letter process
• Concurrent/inpatient review and bed-day management.
2. Demonstrates the effective practice of Case Management Standards of Care including:
• Assessment
• Case Identification and Selection
• Planning
• Monitoring
• Evaluating
• Outcomes
3. Sets appropriate priorities to meet departmental goals and objectives including but not limited to:
• Demonstrates ability to efficiently manage caseload.
• Demonstrates ability to set appropriate priorities.
• Consistently renders prudent and sound decisions.
• Manages multiple tasks while meeting required timeframes.
• Adheres to departmental policies and procedures.
4. Demonstrates knowledge of Health Plan guidelines.
5. Demonstrates knowledge of federal, state, NCQA, and health plan regulatory requirements and approved criteria guidelines.
6. Ensures consistent application of the utilization process.
7. Maintains knowledge of new legislation and disseminates information to providers and co-workers.
8. Demonstrates ability to give concise, articulate and accurate case presentations to Medical Director, UMC, etc including problem solving.
9. Demonstrates cost savings.
10. Consistently demonstrates professional work ethic, collegial interaction with others, and reliability, while contributing to a positive work environment, including but not limited to:
• Professional appearance and demeanor.
• Meets departmental attendance needs on site.
• Participates verbally in group activities, i.e. staff meetings, etc.
• Demonstrates respect to co-workers and customers.
• Works collaboratively with other departments to identify and resolve issues.