(Archived) RN Medical Case Manager (Ambulatory) - Whole Child Model

Department(s): Case Management
Reports to: Supervisor, Case Management
FLSA status: Non-Exempt
Salary Grade: L - $77,000 - $109,000

Job Summary

Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for CalOptima members. This position facilitates communication and coordination among all participants of the health care team and the member to ensure that the services are provided to promote quality cost-effective outcomes.

The Ambulatory Case Manager provides intensive case management to a primarily pediatric population in a process that includes assessment, planning, implementation, coordination, monitoring, and evaluation of the member’s needs.

Position Responsibilities:

• Performs comprehensive disease specific clinical assessment of all identified cases which includes but is not limited to:

• • Assessment of member’s physical, functional, social, and psychological status.
  • Assessment of member’s cultural and linguistic needs.
  • Assessment of caregiver resources and available benefits.

• Develops and implements of a member specific care plan which includes prioritized goals.
• Follow-ups with members and families to assess progress towards goals and identifies barriers to meeting goals.
• Communicates with member’s physicians, specialists, community agencies and vendors to ensure coordination of services.
• Follows CalOptima’s protocol for documenting all case interventions.
  • Facilitates Interdisciplinary Team Meetings as indicated via telephone or onsite.
• Collaborates with interdepartmental staff in case resolution as needed.
• Identifies cases needing manager, director or medical director review or input and routes accordingly.
• Closes cases according to defined case closure according to established guidelines.
• Prepares and maintains appropriate documentation of patient care and progress within the care plan.
• Acts as an advocate in the client’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
• Other projects and duties as assigned.

Possesses the Ability To:

• Maintain and ensure confidentiality of patient information.
• Effectively interview pediatric and adult members and their families to determine the client’s strengths, barriers, functional status, gaps in care, need for specific services/resources, and to establish prioritized member-centric goals.
• Develop a plan, when indicated through multi-disciplinary collaboration which identifies options and goals.
• Adeptly utilize and access computer programs – both Microsoft Office applications and job-specific applications.
• Proactively utilize all available resources for decision making.
• Advocate on behalf of the individual to assure quality of care and attainment of appropriate goals.
• Develop and maintain effective working relationships with all levels of staff, other programs, agencies, and the population served.
• Access and interpret reports and data.
• Perform tasks independently and prioritize workload.
• Apply clinical judgment, independent analysis, and evidenced-based clinical guidelines in decision making.
• Communicate clearly and concisely, both verbally and in writing.
• 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.

Experience & Education:

• Associates Degree in Nursing (ADN) required.
• Current, unrestricted Registered Nurse (RN) license to practice in the State of California required.
• 5+ years Clinical experience, Managed Care experience required.

Preferred Qualifications:

• Bachelor’s Degree in Nursing (BSN) preferred.
• 2+ years Pediatric experience preferred.
• Certified Case Manager license (CCM) preferred.
• Bilingual in English and one of CalOptima’s defined threshold languages (Spanish, Vietnamese, Arabic, Farsi, Korean, Chinese) is preferred.

Knowledge of:

• Guidelines and regulations relevant to case management and utilization management.
• Understand confidentiality and the legal and ethical issues pertaining to case management.
• National Committee for Quality Assurance (NCQA) PHM Standards; Complex Case Management.
• Available community resources.
• Effective charting practices and guidelines.
• Available medical treatments and resources.
• Principles and practices of health care, health care systems, and medical administration.

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

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