TEMPORARY - Medical Case Manager High Risk Pregnancy

Job Summary

Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for members. The Medical Case Manager, High-Risk Pregnancy, will facilitate communication and coordination among all participants of the health care team and the member to ensure that the services provided promote quality, cost-effective outcomes. The incumbent will be a resource for high-risk pregnancy members, delegated plan Case Managers, Personal Care Coordinators (PCCs) and community partners to address medical, behavior and psychosocial concerns. In conjunction with other team members, the incumbent will develop and make recommendations for a comprehensive individualized care plan at all levels of care.

Position Responsibilities

• Reviews and analyzes member health risk assessment (HRA) answers and uses clinical judgment to assign a care management level (CML).
  
• Reviews Interdisciplinary Care Team (ICT) summaries and individual care plans (ICP) to ensure compliance with Centers for Medicare and Medicaid Services (CMS) and Model of Care requirements.
  
• Works collaboratively with the PCCs to develop care plans for members, including those who are pregnant, using member HRA data.
  
• Utilizes all other available data to formulate care plans in the absence of an HRA.
  
• Ensures and facilitates communication between PCCs and delegated plan PCCs to achieve favorable member health outcomes.
  
• Responds appropriately to case management triggers generated as part of the HRA or ICT process.
  
• Anticipates needs for those at risk of transitioning of care and proactively support reducing the risk of re-entering a higher level of care.
  
• Acts as an integral part of the team, providing verbal and written support of member needs.
  
• Collaborates and communicates with the member, family, significant other(s), physicians, health network (HN) designee and other health care providers to support and accomplish goals identified on the individualized care plan in all care settings.
  
• Accepts referrals for case management and serves as a liaison to community agencies, organizations and state personnel.
  
• Provides case management consultation and education to members, their families and the HNs.
  
• Acts as an advocate to assist in the coordination of the client s identified psychosocial needs, utilizing community resources and support when appropriate.
  
• Participates in proactive identification of patients appropriate for care management.
  
• Initiates appropriate follow-up and the development of an individual care plan incorporating assessment, education, resource planning and coordination of services of those patients accepted for case management.
  
• Assists, as requested, to collect and analyze data from initial/annual/updated health risk assessments, stratification tools, outcome measures and internal/external reports to identify trends, individual issues, problems and resources that are most appropriate to meet client s needs.
  
• Develops and maintains a network of current community resources and services where members can be referred for assistance.
  
• Assists with the establishment of measurable standards and reporting for monitoring the OneCare Connect team s internal processes and make recommendations for areas of improvement.
  
• Performs regular review of cases and events to identify patterns/trends and to ensure the department s compliance with CMS, Department of Health Care Services (DHCS) and National Committee for Quality Assurance (NCQA) standards.
  
• Maintains documentation of case management plans/interventions and statistics required to demonstrate activities of the ICT and the impact of case management, quality and care settings that best meet the member s needs.
  
• Serves as a liaison and resource between and the HNs departments, as applicable.
  
• Develops and maintains a good working relationship with all areas.
  
• Completes other projects and duties as assigned.
  

Possesses the Ability to:

• Maintain and ensure confidentiality of patient information.
  
• Effectively interview members to determine strengths, problems prognosis, functional status, goals and need for specific services/resources and to establish short-term and long-term goals.
  
• Develop a plan based on comprehensive assessment of the member s physical, psychosocial, functional, strengths/barriers and mental health needs.
  
• Work well within a team structure, make recommendations to the team and support the recommendations with clinical rationale.
  
• Proactively utilize clinical judgment, independent analysis and evidenced-based clinical guidelines in decision making.
  
• Advocate on behalf of the member to ensure quality of care and attainment of appropriate goals.
  
• Access and interpret reports and data.
  
• Perform tasks independently and prioritize workload.
  
• Problem solve member issues related to health care matters that will impact outcomes.
  
• Work independently and in a professional and effective manner with internal and external constituencies.
  
• Utilize all available resources when making clinical judgment, independent analysis and applying evidenced-based clinical guidelines in the decision-making process.
  
• Establish and maintain effective working relationships with leadership and staff.
  
• Communicate clearly and concisely, both orally and in writing.
  
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems (e.g., CCMS) to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.
  

• Experience & Education
  

  • Associates degree in Nursing (ADN) required.
    
  • Current, unrestricted Registered Nurse (RN) license to practice in the state of Californiarequired.
    
  • 5 years of clinical experience working with pregnancy 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 is also qualifying.
      

Preferred Qualifications

• Bachelor s degree in Nursing (BSN), Public Health or a related field.
  
• Active and unrestricted Registered Nurse CCM certificate.
  
• Bilingual in English and in one of these defined threshold languages (Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese).
  

Knowledge of:

• Guidelines and regulations relevant to case management and utilization management within the assigned area, discharge planning and utilizing community resources for special services.
  
• Understand confidentiality and the legal and ethical issues pertaining to case management.
  
• Medicare and Medicaid (Medi-Cal) services, regulations and populations served.
  
• A wide variety of medical problems, appropriate treatments and resources for medical treatments and resources in the community.
  
• Effective charting practices and guidelines.
  
• Principles and practices of health care, health care systems and medical administration.