Your Role

The Care Management team will serve to support the mission of the department, which is to provide support to patients in maintaining health and wellness in the outpatient setting. The Case Management - Nurse, Senior will report to the Manager of Care Management. In this role you will play a pivotal role in assessing member needs, providing clinical education, as well as care coordination with providers, medical groups, and community resources. You will be responsible for managing and coordinating patient care, ensuring that our members receive the highest quality of care and services. Care Managers perform care management (CM) activities demonstrating clinical judgement and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating physicians.

Your Work

In this role, you will:

• Determine appropriateness of referral for CM services, mental health, and social services
• Assess members health behaviors, cultural influences and clients belief/value system. Evaluate all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers
• Research and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type. Adjust plans or create contingency plans as necessary
• Identify appropriate programs and services that align with member needs and preferences
• Initiate timely Individualized Care Plans (ICP) based on Health Risk Assessment (HRA) completion, participation in and documentation of Interdisciplinary meetings (ICT), assisting in transitions of care across all ages
• Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)
• Conduct member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases
• Research opportunities for improvement in assessment methodology and actively promote continuous improvement. Anticipate potential barriers while establishing realistic goals to ensure success for the member, providers, and BSC
• Determine realistic goals and objectives and provide appropriate alternatives. Actively soliciting clients involvement
• Recognize need for contingency plans throughout the healthcare process
• Provide education and support to members and their families regarding health conditions, treatment options, and community resources
• Follow up with members as appropriate to ensure they have successfully connected with recommended programs and services

Your Knowledge and Experience

• Requires a current and valid CA RN License or valid RN license(s) from other state(s). Preferred licensure from a compact state. If assigned to another state, must maintain an active, unrestricted RN license in assigned state(s) or the ability to obtain required RN license (in addition to primary state license) within 90 days of hire
• Bachelor of Science in Nursing or advanced degree preferred
• Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
• Requires 5 years experience in nursing, healthcare, or related field
• A minimum of 3 years managed care experience in inpatient, outpatient, or managed care environment preferred
• Health insurance/managed care experience preferred
• Transitions of care experience preferred
• Strong knowledge of healthcare delivery systems, managed care principles, and care coordination
• Excellent communication skills