Medical Case Manager (RN-Case Mgt)
Location :
Orange County
Job Type :
Temp/Contract
Reference Code :
376
Required Years of Experience :
3 years
Job Description :
Overview:
CalOptima Health is seeking a highly motivated an experienced TEMP - Medical Case Manager (Case Mgt) to join our team. Case Management is an advanced specialty collaborative practice responsible for providing ongoing case management services for CalOptima Health’s members. The Medical Case Manager will facilitate communication and coordination among all participants of the health care team and CalOptima Health’s members to ensure the services provided promote quality and cost-effective outcomes for all members. The incumbent will be responsible for providing intensive case management, which includes assessment, planning, implementation, coordination, monitoring and evaluation of the member’s needs.
Position Responsibilities:
- Analyzes requests with the objective of monitoring utilization of services, this includes medical appropriateness and identifying potential high cost, complex cases for outpatient case management intervention.
- Reviews and evaluates proposed services utilizing medical criteria and/or established policies and procedures.
- Determines the appropriate action for the service being requested for approval, modification or denial, and refers to the Medical Director for review when necessary.
- Reviews inpatient setting requests to determine if surgery and/or medical care is appropriate.
- Identifies diagnosis and determines need for continuing hospitalizations; monitors the inpatient length of stay as per established guidelines and professional judgment.
- Initiates contact with patient, family, and treating physicians to obtain additional information or to introduce the role of case management as needed.
- For short-term cases, conducts a thorough and objective assessment of the member’s status including physical, psychosocial and environmental.
- Develops, implements and monitors a care plan through the interdisciplinary team process in conjunction with the individual member and family in internal and external settings across the continuum of care.
- Provides cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.
- Assesses member’s status and progress; if progress is static or regressive determines reason and encourages appropriate referrals to out-patient case management or make appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
- Establishes means of communication and collaboration with other team members, physicians, community agencies, and administrators.
- Prepares and maintains appropriate documentation of patient care and progress within the care plan.
- Acts as an advocate in the client’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
- Collaborates with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem and solving complex cases.
- Documents clinical information into the case notes along with the rationale for all decisions in the Guiding Care system.
- Other projects and duties as assigned.
Required Qualifications :
Minimum Qualifications:
- Associate degree in nursing (ADN) or related field required PLUS 3 years of clinical experience 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.
Preferred Qualifications:
- Bachelor of Science in Nursing (BSN) degree or related field.
- Case Management Certification (CCM).
- Bilingual in English and one of CalOptima Health’s defined threshold languages (Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese).
Required Licensure / Certifications:
- Current, unrestricted Registered Nurse (RN) license to practice in the state of California required.
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