Complex Care Manager - RN

Qualifications

• Assess members to identify medical physical and psychosocial needs.
• Ensures and evaluates clinical appropriateness of care plan by evaluating assessment findings against evidence based guidelines clinical practice guidelines and/or nationally developed guidelines for development of an appropriate plan of care based on individual needs and findings and including physical psychological social and spiritual factors that may influence member health status.
• Provides effective case management by identifying potential barriers to adherence to plan of care and modifying plan by mutual agreement with the member to ensure health care needs and goals are identified implemented and met.
• Educates member about health prevention guidelines and disease states using approved evidencebased guidelines.
• Facilitates care coordination across the care continuum (home hospital home health or nursing facility) identifies community resources and makes referrals as appropriate. Connects members and families with appropriate community resources.
• Documents accurate and complete data for all member contacts in the appropriate database. Promotes member activation and engagement to ensure optimal selfmanagement skills and health outcomes.
• Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations.
• Enhances department and organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
• Actively participates in staff meetings educational offerings and interdisciplinary team meetings.
• Complies with all regulatory and quality agency standards including: Centers for Medicare and Medicaid Services (CMS) Department of Managed Health Care (DMHC) Department of Health Services (DHS) and accreditation bodies standards such as the National Commission of Quality Assurance (NCQA) as it relates to care management activities; serves as a resource for other departments.
• Addresses and followsup with all identified member quality concerns using approved processes.

Requirements

• Bachelors degree from a four year college in nursing or related field.
• Current and active California RN License (Graduation from an accredited school of nursing).
• 3 5 years of clinical experience with geriatric population (Acute Ambulatory care SNF and/or LTC).
• Medicare/MediCal experience in managed care environment.
• Basic knowledge of related NCQA standards CMS and DHCS regulations.
• Navigate and access multiple software systems without error.
• Proficient in MS Office Suite.
• Medical and clinical terminology conversant.
• Meets core competencies and clinical skill set for entry level Basic ICD9/10 and CPT coding knowledge.

Preferred Qualifications

• 2 years of case management experience in a medical group IPA and/or HMO setting.
• Case Management Certification (CCM) Accredited Case Management (ACM) or Certified Professional of Utilization Management (CPUM).
• Proficiency in second language (includes but not limited to Korean Spanish Tagalog Chinese Vietnamese Farsi and Russian).

Required Experience:

Manager