A Clinical Case Manager coordinates medical care and provides advocacy to help people get the best and most affordable care. Helps patients navigate insurance and hospital bureaucracies and access information. May work with patients who have chronic illnesses or other complex medical needs. Works at a hospital or other healthcare facility; may follow patients throughout the span of their treatment and travel to different doctors' offices, hospitals or a patient's home.
95% - Medical Review Support 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. Reviews requests for medical appropriateness for CBAS services utilizing Medi-Cal criteria or established policies and procedures. Performs and/or reviews clinical assessments including California Department of Aging (CDA) approved standardized tools such as CBAS Eligibility Determination Tool (CEDT) and CBAS Individual Plan of Care (IPC). Determines the appropriate decision regarding the service being requested for approval, modification or denial, and refers to the Medical Director when necessary. Screens CBAS requests for Medical Director review, gathers pertinent medical information prior to submission to the Medical Director, communicates the Medical Director's decision with the requestor and documents follow-up in the care management system. Initiates and follows through with contacting the member's caregiver, family, CBAS provider and treating physician as needed to obtain additional information for utilization review. Complete all documentation accurately and appropriately for data entry in the care management system during authorization review, assessment and communication to include any authorization updates. Accurately codes each diagnosis of service and procedures according to the established policy and procedure. Analyzes all requests with the objective of monitoring utilization of services, which includes reviewing for medical appropriateness and identifying potentially high-cost complex cases requiring high-level case management intervention. Establishes a means of communication with other team members, Medical Directors, community support providers including CalAIM and IHSS, and skilled nursing facilities. Meets identified productivity and quality of work standards on an ongoing basis. 5% - Other Completes other projects and duties as assigned.
Minimum Qualifications:
Associate degree in Nursing (ADN) PLUS 3 years of nursing experience with the health needs of the population served; 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.
Preferred Qualifications:
1 year of authorization review experience. Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese). Required Licensure /
Certifications:
Current unrestricted Registered Nurse (RN) license to practice in the state of California required.
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.
