• RN Care Coordination Case Manager I

    Job Locations US-CA-Fairfield
    Job ID
    2018-1208
    Category
    Health Services
  • Overview

    To initiate and coordinate a multidisciplinary team approach to case management. Engages the member/member’s representative in a care plan that assists a 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.

    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.
    • Ensures a smooth implementation and continuum of care via effective and frequent communication with providers, members, and identified health care designee.
    • 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 PHC Case Management System for members in case management.
    • Applies evidence-based interventions based upon member’s agreed upon goals
    • 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 PHC providers, as assigned.
    • Notifies Claims department of benefit-related decisions and CM intervention to ensure appropriate payment of approved services.
    • Other duties as assigned.

    Qualifications

    Education and Experience

    2years 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 with emphasis on Utilization Management or Case Management preferred.

     

    Special Skills, Licenses and Certifications

    Current California Registered Nurse License. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business. Bilingual skills in Spanish preferred.

     

    Performance Based Competencies

    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.

     

    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.

     

     

     

    Additional Preferred Skills:  Public Health Nurse (PHN), CA Children's Services, School Nurse, or Pediatric experience in a clinical or community based setting strongly desired.

     

     

    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.

     

    IMPORTANT DISCLAIMER NOTICE

     

    The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

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