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Job Description

• Department: CM - Clinic Ops Admin
• Salary Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615)
• Work Arrangement: Full Telework
  
  **This position is eligible for telework in California.**

• 85% - Care Management
  • Assesses member needs using a standardized health needs assessment or health risk assessment.
  • Performs comprehensive, disease specific, clinical assessments of all identified cases, which includes but is not limited to, assessment of:
  • Member's physical, functional, social and psychological status
  • Member's cultural and linguistic needs
  • Caregiver resources and available benefits
  • Performs post-discharge assessments to identify member's post-hospital or post-emergency department discharge needs including but not limited to:
  • Member's physical, functional, social and psychological status
  • Member's cultural and linguistic needs
  • Caregiver resources and available benefits
  • Follow-up provider care and ensuring scheduled appointments
  • Durable medical equipment and supplies
  • Community resources
  • Develops and implements a member's specific care plan which includes prioritized Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) goals.
  • Reviews, modifies and updates care plans continuously to reflect the member's needs, at minimum, annually or upon change in condition.
  • Schedules follow-ups to assess progress towards goals and identifies barriers to meeting goals.
  • Provides regular outreach to assigned members along with members from a worklist and evaluates quality of service given to members according to department contact standards.
  • Coordinates care and services with members, members' family members/representatives and other providers, as appropriate, including community supports and Long-Term Services and Supports (LTSS).
  • Communicates with member's physicians, specialists, community agencies and vendors to ensure coordination of services.
  • Facilitates referrals to behavioral health/substance use disorder services and identifies and makes referrals to LTSS department, community supports and community resources.
  • Facilitates and participates in Interdisciplinary Team meetings as applicable.
  • Collaborates with interdepartmental staff in case resolution as needed.
  • Identifies cases needing supervisor, manager, director or medical director review or input, routes accordingly and closes cases according to procedures and guidelines in a timely manner.
  • Advocates in the member's best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
    
    
• 10% - Administrative Support
  • Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
  • Follows CalOptima Health's protocol for documenting all case interventions.
  • Prepares and maintains appropriate documentation of patient care and progress within the care plan.
    
    
• 5%
• Completes other projects and duties as assigned.

• 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.
  

• Bachelor of Science in Nursing (BSN) degree or related field.
  
• 2 years of pediatric experience.
  
• Certified Case Manager (CCM) certificate.
  
• Bilingual in English and one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).

• Current unrestricted Registered Nurse (RN) license to practice in the state of California required.

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.