Whole Child Model (WCM) Case Manager
- Conducts a comprehensive member assessment that includes but is not limited to the review of all medical claims data and health plan information available, health plan completed health needs assessment (HNA), and any additional specialized assessments as appropriate (PHQ-9, AUDIT, etc.). Develops an Individualized Care Plan (ICP) as guided by the by the comprehensive member assessment that includes SMART goals that are developed with the member, prioritized and inclusive of member/family goals. Monitors and evaluates the effectiveness of the care management plan and modifies as necessary; reviewed for modification no less than when a change in the member’s medical condition or annually. Interfaces with Medical Director as needed (related to clinical “patient care/treatment” concerns).
- Facilitates Interdisciplinary Care Team (ICT) meetings as required for high risk member. Coordinates needed services for the member as appropriate to fulfill the member’s CM care plan and physician(s) treatment plan. These tasks include but are not limited to the following: facilitating exchange of member information among all treating providers – especially between the CCS treating specialists and the member’s PCP; participating in Medical Therapy Unit case conferences as needed; facilitating the inclusion on regional center case managers, behavioral specialists and County substance use and/or mental health providers in ICT meetings and/or other care plan discussions as appropriate to the member’s care team; and ensuring receipt of needed treatment and support care services. Collaborate with member’s family and physicians for seamless coordination of care and services on an ongoing basis.
- Conducts outbound calls to members/parents to fulfill the member’s plan of care. Manages an appropriate /caseload of members assigned complex, care coordination and basic case management levels. Creates and manages all cases in Essette (electronic care management platform); provides appropriate documentation including evidence that the WCM requirements for case management are met. Provides members/families member friendly care plans. Facilitates member “aging out” processes for the WCM program and for transitioning from pediatric to adult specialty providers on an individualized basis. Ensures smooth transfer of CCS members into or out of County CCS programs. Facilitates ongoing education and information about resources that may be helpful to members/families and all referrals to member-eligible programs such as the High Risk Infant Follow-Up (HRIF) Program.
- Meet health plan requirements for turn-around-times for assessments, care plans and ICTs.
- Review and approve incoming prior authorizations from CCS-paneled specialists for treatment services or facilitate medical director review and approval. Manage all CCS outpatient referral authorizations in IDX and ensure the daily management of the incoming dedicated CCS Fax for physician authorizations. Communicate directly with CCS treating specialists as necessary for treatment and service authorization approvals.
- Provide guidance to and oversight of the dedicated CCS Personal Care Coordinator.
Minimum Education: High School Diploma required. BA preferred.
Minimum Experience: Clinical experience with complex pediatric patients/members (minimum of 2 years). Familiarity with developing care plans and assessments preferred.
Req. Certification/Licensure: RN unrestricted active license required.