Job Description

Case Management Nurse

To initiate and coordinate a multidisciplinary team approach to case management. Engages the member/member's representative in a care plan that assists the member in meeting his/her health and wellness goals. Collaborates, assesses, plans, facilitates, evaluates, and advocates to meet the comprehensive medical, behavioral, and psychosocial needs of the member, while promoting quality and cost-effective outcomes.

Essential Duties and Responsibilities

Provides case management services independently for a caseload ranging in complexity from basic to complex; acuity levels 1-4; performs field-based case management (acuity level 5) with supervision. Initiates and coordinates individualized care plan for assigned members, addressing both clinical and non-clinical components, and ensuring the care plan is available to both the member and primary care provider. Resolves member needs by utilizing multidisciplinary team strategies, including Health Services Integrated Rounds Meetings. Ensures a smooth implementation and continuum of care via effective and frequent communication with providers, members, and identified health care designee. Elicits medical information from providers and reviews medical records, applying clinical judgment to identify case management needs and support care coordination activities. Facilitates medical records retrieval through appropriate channels and established submission processes. Communicates clearly and effectively through all mediums of communication with members, providers, vendors, community partners, and Partnership employees. Coordinates referrals and authorizations for services required to improve the member's health status. Maintains accurate and timely documentation, records, and case files in the Partnership Case Management System for members in case management. Applies evidence-based interventions based upon member's agreed upon goals/ priorities Develops and maintains knowledge of a community based network of alternative modes of care; aids member to connect with community-based organizations to support and enhance wellness. Answers and triages department calls, and distributes department referrals with guidance, in accordance with identified department service levels. Collaborates and coordinates with other internal departments to identify members suitable for case management.

Actively participates in essential skills training, unit and departmental assigned learning, and other departmental activities as assigned. Functions collaboratively in a team environment, including acting as a support and resource to other staff. Coordinates and participates in meetings with Partnership providers, as assigned. Collaborates with other departments with coordination of care needs through the course of case management services. Demonstrates competence in NCQA documentation standards. Exhibits high professional standards as outlined in the CA Nurse Practice Act and Partnership's Code of Conduct. Performs other duties as assigned by the direct supervisor, including the assumption of new duties.

Education and Experience

Associate's degree in Nursing required; Bachelor's degree in Nursing (or higher) preferred. 2 years of experience preferred, to include at least one (1) year of case management experience and one (1) year in an acute care setting; or equivalent combination of education and experience. General knowledge of managed care and/or experience with Medicaid population preferred.

Special Skills, Licenses and Certifications

Current and unrestricted California Registered Nurse License. Valid California driver's license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business. Bilingual skills in an approved threshold language is preferred.

Performance Based Competencies

Strong organizational, communication, critical thinking skills and attention to detail required. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines. Effective telephone and computer data entry skills required. Experience in managed care business practices and ability to access data information using various computer systems. Excellent English written and verbal communication skills required.

Work Environment And Physical Demands

Able to utilize multiple computer platforms simultaneously. Daily use of telephone and computer for most of the day. Standard cubicle workstation. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs..

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan's policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$ 106,667.05 - $ 138,667.16

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