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Job Description

• 95% - Case Management
  • 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 and analyzes member health risk assessment (HRA) answers and uses clinical judgment to assign a care management level (CML).
  • Reviews Interdisciplinary Care Team (ICT) summaries and individual care plans (ICP) to ensure compliance with Centers for Medicare and Medicaid Services (CMS) and Model of Care requirements.
  • Works collaboratively with the PCCs to develop care plans for members, including those who are pregnant, using member HRA data.
  • Utilizes all other available data to formulate care plans in the absence of an HRA.
  • Ensures and facilitates communication between PCCs and delegated plan PCCs to achieve favorable member health outcomes.
  • Responds appropriately to case management triggers generated as part of the HRA or ICT process.
  • Anticipates needs for those at risk of transitioning of care and proactively support reducing the risk of re-entering a higher level of care.
  • Acts as an integral part of the team, providing verbal and written support of member needs.
  • Collaborates and communicates with the member, family, significant other(s), physicians, health network (HN) designee and other health care providers to support and accomplish goals identified on the individualized care plan in all care settings.
  • Accepts referrals for case management and serves as CalOptima Health's liaison to community agencies, organizations and state personnel.
  • Provides case management consultation and education to members, their families and the HNs.
  • Acts as an advocate to assist in the coordination of the client's identified psychosocial needs, utilizing community resources and support when appropriate.
  • Participates in proactive identification of patients appropriate for care management.
  • Initiates appropriate follow-up and the development of an individual care plan incorporating assessment, education, resource planning and coordination of services of those patients accepted for case management.
  • Assists, as requested, to collect and analyze data from initial/annual/updated health risk assessments, stratification tools, outcome measures and internal/external reports to identify trends, individual issues, problems and resources that are most appropriate to meet client's needs.
  • Develops and maintains a network of current community resources and services where members can be referred for assistance.
  • Performs regular review of cases and events to identify patterns/trends and to ensure the department's compliance with CMS, Department of Health Care Services (DHCS) and National Committee for Quality Assurance (NCQA) standards.
  • Maintains documentation of case management plans/interventions and statistics required to demonstrate activities of the ICT and the impact of case management, quality and care settings that best meet the member's needs.
  • Serves as a liaison and resource between CalOptima Health and the HNs departments, as applicable.
  • Develops and maintains a good working relationship with all areas.
    
    
• 5% - Other
  • Completes other projects and duties as assigned.

• High school diploma or equivalent PLUS 1 year of clinical experience working with pregnancy and/or managed care experience required; 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.

• Associate degree in nursing (ADN), public health or a related field.
  
• Active and unrestricted Registered Nurse CCM certificate.
  
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).

• Current unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California required.

• 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.

• 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

• You'll enjoy competitive compensation for this role.
  • Our current hiring range is: Pay Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947).
    • The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.
      
      
• This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**)
  
  ***Training will be held in the office for the first 4 weeks from 8:00am - 5:00pm, on Tuesdays and Thursdays.
  
  
• A comprehensive benefits package
• CalPERS pension program and additional retirement packages.
• Additional benefits and perks including:
  • A generous PTO program
  • A quality work life balance
  • Various wellness programs
  • Tuition Reimbursement
  • Professional development opportunities
  • Career development opportunities
  • Flexible scheduling
  • And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.

• 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.

• 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.

• 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.