Complex Case Manager, Nurse​/Req

Overview

Complex Case Manager, Nurse / Job Req  (Manufacturing)

Hybrid:
Applicants must be a California resident as of their first day of employment.

• Perform the primary functions of assessment, planning, facilitation and advocacy through collaboration with the member and other health care resources involved in the members care.
• Work closely with licensed and unlicensed staff to co-manage the care of complex cases telephonically through regular contact with members, caretakers, healthcare professionals and others involved in the members care.
• Carry a caseload of members individually and co-managed as a team.
• The nurse will act as a subject matter expert on the nursing process and perspective for the team.
• The nurse will be responsible for triage and all aspects of the nursing process, including assessing, diagnosing, planning, implementing, and evaluating care.
• Develop multi-disciplinary care plans with the input of the member and PCP to address identified member problems using evidence-based goals and interventions.
• Participate in the ongoing process of identifying the health plan’s members who are most at-risk of poor health outcomes and in need of care management services.
• Participate in weekly Multidisciplinary Care Team Meetings and be able to present complex medical cases before the department-wide team.
• The nurse will work with Health Homes members enrolled in internal Community-Based Care Management Entities (CB-CME) per Department of Health Care Services guidelines.
• Work collaboratively with health plan providers, particularly members’ primary care providers and specialists, in order to provide highly coordinated and often specialized care.
• Assess member medical and social determinants of health and communicate with providers, members, and community resources as necessary, to support the planning, implementation and evaluation of care management programs.
• Employ a patient advocacy approach with a seamless integration of services as required and balanced within the member's benefit structure.
• Complete other duties and special projects as assigned.

• Communicate and coordinate required services for members with PCPs and specialists.
• Manage, document, and maintain casework in accordance with NCQA accreditation guidelines and state regulators.
• Build and maintain effective relationships with designated members and those members’ families or caregivers.
• Maintain case management records.
• Develop appropriate member care plans and appropriate member assessments.
• Serve as a clinical resource to staff, as needed.
• Perform writing, administration, analysis, and report preparation.
• Research and develop working relationships with appropriate community resources to service members.
• Provide direction to ancillary team/pod staff members who will provide additional coordination activities for health plan members being case managed.
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

Constant and close visual work at desk or computer. Constant sitting and working stant data entry using keyboard and/or mouse. Frequent use of telephone headset. Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. Frequent lifting of folders and other objects weighing between 0 and 30 lbs. Frequent walking and standing.

Education or training equivalent to:
BSN or MSN required. Registered Nurse license, active and unrestricted licensed in the State of California before start of work. Certification in case management (CCM etc.) preferred or willing to become certified within 12 months of hire or a date agreed to by supervisor.

Minimum years of additional related experience:

Three years experience in clinical case management required. Three years of clinical experience in an acute care setting desired. Masters in Case Management will be considered in lieu of the above listed required clinical CM and desired acute experience.

Special Qualifications (Skills, Abilities, License):

Excellent verbal…