California State University, San Bernardino (CSUSB)
5500 University Parkway, San Bernardino, CA 92407, USA
Job Summary: Under the general direction of a medical provider and the Executive Director, the Registered Nurse III (RN III) is responsible for the development and implementation of nursing standards, policies, and procedures for the Student Health Center (SHC), and oversees and directs the nursing services for one or more specialty areas for the SHC. Coordinates the clinical operations in collaboration with the Medical Chief of Staff and the Executive Director. Major duties and responsibilities: Nursing Lead Functions as nursing clinical lead; implements independent decisions based on the day-to-day clinic needs in the Student Health Center (SHC). Adjusts the clinical schedule when possible to balance provider time based on patient acuity and utilization. Assists with coordinating special program needs to meet student admission requirements such as Nursing Department physical examinations, international student immunization requirements. Holds regular Nursing Staff Meetings to provide nursing updates; ensures meeting minutes are documented. Schedules and assigns Nursing work to ensure adequate coverage, training and orienting employees, and providing input to employee selection and performance evaluations; identify professional growth and development needs for assigned staff and communicate needs to supervisor; develop and implement in-service training. Coordinates daily nursing operations and ensure appropriate staffing levels to meet clinic needs. May assist in developing and monitoring the nursing budget. Accreditation: developing nursing standards, policies, procedures, protocols and standing orders in collaboration with other team members; Maintenance of logs and facility compliance with accreditation standards. Addresses patient concerns, refers to administrator when warranted. Clinic Coordination/Special Projects Serve as liaison between nursing staff, providers, front office and other clinical team members to ensure effective communication in support of patient care; review schedules to anticipate staffing shortages or other challenges in order to avert them or plan ahead; lead weekly team meeting. Oversees the vaccine program, including but not limited to, overseeing proper storage/handling/administration and staff-related training • Leads and coordinates specialty clinics (e.g., flu vaccine), health fairs and student orientations. Assists in the implementation and operationalization of new services and the ongoing improvement of current ones. Leads Nursing Peer Review and Quality Improvement and collaborates with other team members on Emergency Preparedness, Infection Control & Prevention and Accreditation Assists in monitoring compliance with infection control and prevention policies and procedures. Participates in clinic and staff conferences and other presentations when appropriate. Nursing Triage/Back up Nursing Coverage Serve as Nurse Lead for triage questions. Serve as back up triage RNs as needed. Utilizing established triage protocols, functions as the telephone/walk-in triage nurse by assessing patients’ signs and symptoms to determine appropriate disposition (schedules same-day, urgent or future appointments using electronic health records system) and/or treatment. Utilizing standing orders provides first aid to student, staff, faculty and campus visitors. Per provider request, will contact patients to give information regarding referrals, prescriptions, recheck appointments. Provide sexual health education, counseling and care, including administration of medication abortion services. May serve as backup in preparing patients for telehealth and medical examinations and treatment • May perform routine laboratory testing (e.g., urinalysis); may obtain lab samples obtained my medical providers for pick up by the lab. Assists with medical examinations and procedures as requested by medical providers. Provides education counseling on a wide variety of health topics (e.g., STIs, contraception) •Responsible for following Tuberculosis Screening Guidelines - administering PPDs, ordering chest x-rays, ordering laboratory testing and facilitate follow up appointments for patients, when needed. With prior approval from individual providers, communicate normal lab results to students; for results outside of normal limits, facilitate appointment scheduling with a provider. Under standing orders will evaluate requests for HCG including patient assessment, testing, pregnancy options counseling, and appropriate referrals. Other Serve on clinical team and related search committees. Engage in professional development activities to remain up-to-date and to meet ongoing licensure requirements; completes all department and university required trainings as assigned. Perform other related duties supporting the operation of the SHC as assigned. Participate in division and University committees and initiatives as assigned. Minimum Qualifications: Required Education and Experience Three years of progressively responsible professional nursing experience which has provided evidence of the ability to perform administrative and lead responsibilities; or equivalent combination of education and experience which also provides the required knowledge and (including the ability to work independently in specialized nursing activities) and support the overall nursing program within the Student Health Center Possess and maintain a valid license as a Registered Nurse in the State of California and certification in CPR/AED. Required Qualifications Possess a working knowledge of effective supervisory methods and techniques; more comprehensive understanding of nursing programs and specialties; possess broad and specialized nursing knowledge that supports the performance of specialized duties in such areas as, but not limited to, triage and assessment, patient counseling, and staffing specialized nursing clinics; broad knowledge of clinic operations and the development and implementation of a nursing program, including procedures and protocols; thorough knowledge of professional nursing principles, methods and procedures; anatomy and physiology applicable to assigned duties; medical supplies and equipment used in nursing practice; and the uses and effect of medications and narcotics; working knowledge of applicable state and federal laws and regulations pertaining to registered nursing and the scope of practice limitations of clinic support staff. Ability to provide effective work direction; plan and organize the work of others; assess, plan, develop and implement and evaluate a nursing program which may include on or more nursing specialties or clinics; ability to effectively apply specialized nursing skills; ability to effectively apply nursing knowledge and demonstrate proper techniques and skills in performing nursing duties; accurately observe and record symptoms, behaviors, and reactions to treatments in order to make a nursing diagnosis; respond with therapy to treatment reactions; use applicable health center automated systems to perform duties and maintain records and prepare reports; gain the cooperation of patients; analyze emergency situations and take prompt action; maintain patient confidentiality and privacy in compliance with applicable state and federal laws and regulations; maintain effective working relationships with practitioners and other health center support staff; and be sensitive to and communicate effective with patients from diverse backgrounds. Preferred Qualifications Commitment to health equity practices. Ability to work effectively and diplomatically with a diverse team. Experience in college health service or with adolescent or young adult age groups. Medical practice management experience. A Master of Science in Nursing degree. Five or more years of progressively responsible professional nursing experience is preferred. Ability to work effectively and diplomatically with a diverse team. Compensation and Benefits: Anticipated Hiring Range: $4,793 - $9,249 per month Classification Salary Range: $4,793 - $9,249 per month The salary offered will take into account internal equity and experience among other factors. The CSU system provides a comprehensive benefit package that includes medical, dental and vision plans, membership in the California Public Employees Retirement System (CalPERS), sick and vacation time, and 15 paid holidays a year. Eligible employees are also able to participate in the fee waiver education program. A summary of benefit information can be found here . Position Information: Work status: Full-time/Exempt/Probationary Academic year schedule: Monday through Friday (8:00 am - 5:00 pm), some evenings/weekends. Summer schedule: Monday through Thursday (7:00 am - 5:30 pm), some evenings/weekends. The posting has been extend and is open until filled. We will review applicant for consideration that have applied by April 9th, 2024. Afterwards, the position may close when an adequate number of qualified candidates are received. As of January 1, 2022, the CSU Out-of-State Employment Policy prohibits the hiring of employees to perform CSU-related work outside the state of California. California State University, San Bernardino in not a sponsoring agency for staff or management positions (i.e. H1-B Visas). Conditions of Employment Background Check Satisfactory completion of a background check (including a criminal records check) is required for employment. CSU will make a conditional offer of employment, which may be rescinded if the background check reveals disqualifying information, and/or it is discovered that the candidate knowingly withheld or falsified information. Failure to satisfactorily complete the background check may affect the continued employment of a current CSU employee who was conditionally offered the position. Mandated Reporter The person holding this position is considered a `mandated reporter' under the California Child Abuse and Neglect Reporting Act and is required to comply with the requirements set forth in CSU Executive Order 1083 as a condition of employment. I-9 CSUSB hires only individuals lawfully authorized to work in the United States. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification form upon hire. See Form I-9 Acceptable Documents at https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents . Statement of Commitment to Diversity In our commitment to the furthering of knowledge and fulfilling our educational mission, California State University, San Bernardino seeks a campus climate that welcomes, celebrates, and promotes respect for the entire variety of human experience. We welcome people from all backgrounds, and we seek to include knowledge and values from many cultures in the curriculum and extra-curricular life of the campus community. We will create, promote, and maintain activities and programs that further our understanding of individual and group diversity. We will also develop and communicate policies and promote values that discourage intolerance and discrimination. California State University, San Bernardino is proud to be an Affirmative Action/Equal Opportunity Employer. We recruit, hire, train, and administer all personnel actions without regard to race, ethnicity, religion, color, caste, national origin, ancestry, age, sex, gender, gender identity, gender expression, sexual orientation, socioeconomic status, genetic information, medical condition, disability, marital status, protected military or veteran status, or any other status protected by applicable law. This position adheres to CSU policies against Sex Discrimination, Sexual Harassment, and Sexual Violence, including Domestic Violence, Dating Violence, and Stalking. This requires completion of Sexual Violence Prevention Training within 6 months of assuming employment and on a two-year basis thereafter. (Executive Order 1096) For more information about Diversity & Inclusion at CSUSB, please visit https://www.csusb.edu/human-resources/diversity-inclusion Closing Statement: Reasonable Accommodation We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact CSUSB Benefits at Benefits@csusb.edu Smoking CSUSB is a smoke and tobacco-free campus. See policy at https://calstate.policystat.com/policy/6591951/latest/ . Clery Act In compliance with state and federal crime awareness and campus security legislation, including The Jeanne Clery Disclosure of Campus Security Policy and Crime Statistics Act, California Education Code section 67380, and the Higher Education Opportunity Act (HEOA), the Cal State San Bernardino Annual Security and Fire Safety Report is available at: https://www.csusb.edu/clery-act Advertised: Mar 26 2024 Pacific Daylight Time Applications close: Closing Date/Time:
Job Summary: Under the general direction of a medical provider and the Executive Director, the Registered Nurse III (RN III) is responsible for the development and implementation of nursing standards, policies, and procedures for the Student Health Center (SHC), and oversees and directs the nursing services for one or more specialty areas for the SHC. Coordinates the clinical operations in collaboration with the Medical Chief of Staff and the Executive Director. Major duties and responsibilities: Nursing Lead Functions as nursing clinical lead; implements independent decisions based on the day-to-day clinic needs in the Student Health Center (SHC). Adjusts the clinical schedule when possible to balance provider time based on patient acuity and utilization. Assists with coordinating special program needs to meet student admission requirements such as Nursing Department physical examinations, international student immunization requirements. Holds regular Nursing Staff Meetings to provide nursing updates; ensures meeting minutes are documented. Schedules and assigns Nursing work to ensure adequate coverage, training and orienting employees, and providing input to employee selection and performance evaluations; identify professional growth and development needs for assigned staff and communicate needs to supervisor; develop and implement in-service training. Coordinates daily nursing operations and ensure appropriate staffing levels to meet clinic needs. May assist in developing and monitoring the nursing budget. Accreditation: developing nursing standards, policies, procedures, protocols and standing orders in collaboration with other team members; Maintenance of logs and facility compliance with accreditation standards. Addresses patient concerns, refers to administrator when warranted. Clinic Coordination/Special Projects Serve as liaison between nursing staff, providers, front office and other clinical team members to ensure effective communication in support of patient care; review schedules to anticipate staffing shortages or other challenges in order to avert them or plan ahead; lead weekly team meeting. Oversees the vaccine program, including but not limited to, overseeing proper storage/handling/administration and staff-related training • Leads and coordinates specialty clinics (e.g., flu vaccine), health fairs and student orientations. Assists in the implementation and operationalization of new services and the ongoing improvement of current ones. Leads Nursing Peer Review and Quality Improvement and collaborates with other team members on Emergency Preparedness, Infection Control & Prevention and Accreditation Assists in monitoring compliance with infection control and prevention policies and procedures. Participates in clinic and staff conferences and other presentations when appropriate. Nursing Triage/Back up Nursing Coverage Serve as Nurse Lead for triage questions. Serve as back up triage RNs as needed. Utilizing established triage protocols, functions as the telephone/walk-in triage nurse by assessing patients’ signs and symptoms to determine appropriate disposition (schedules same-day, urgent or future appointments using electronic health records system) and/or treatment. Utilizing standing orders provides first aid to student, staff, faculty and campus visitors. Per provider request, will contact patients to give information regarding referrals, prescriptions, recheck appointments. Provide sexual health education, counseling and care, including administration of medication abortion services. May serve as backup in preparing patients for telehealth and medical examinations and treatment • May perform routine laboratory testing (e.g., urinalysis); may obtain lab samples obtained my medical providers for pick up by the lab. Assists with medical examinations and procedures as requested by medical providers. Provides education counseling on a wide variety of health topics (e.g., STIs, contraception) •Responsible for following Tuberculosis Screening Guidelines - administering PPDs, ordering chest x-rays, ordering laboratory testing and facilitate follow up appointments for patients, when needed. With prior approval from individual providers, communicate normal lab results to students; for results outside of normal limits, facilitate appointment scheduling with a provider. Under standing orders will evaluate requests for HCG including patient assessment, testing, pregnancy options counseling, and appropriate referrals. Other Serve on clinical team and related search committees. Engage in professional development activities to remain up-to-date and to meet ongoing licensure requirements; completes all department and university required trainings as assigned. Perform other related duties supporting the operation of the SHC as assigned. Participate in division and University committees and initiatives as assigned. Minimum Qualifications: Required Education and Experience Three years of progressively responsible professional nursing experience which has provided evidence of the ability to perform administrative and lead responsibilities; or equivalent combination of education and experience which also provides the required knowledge and (including the ability to work independently in specialized nursing activities) and support the overall nursing program within the Student Health Center Possess and maintain a valid license as a Registered Nurse in the State of California and certification in CPR/AED. Required Qualifications Possess a working knowledge of effective supervisory methods and techniques; more comprehensive understanding of nursing programs and specialties; possess broad and specialized nursing knowledge that supports the performance of specialized duties in such areas as, but not limited to, triage and assessment, patient counseling, and staffing specialized nursing clinics; broad knowledge of clinic operations and the development and implementation of a nursing program, including procedures and protocols; thorough knowledge of professional nursing principles, methods and procedures; anatomy and physiology applicable to assigned duties; medical supplies and equipment used in nursing practice; and the uses and effect of medications and narcotics; working knowledge of applicable state and federal laws and regulations pertaining to registered nursing and the scope of practice limitations of clinic support staff. Ability to provide effective work direction; plan and organize the work of others; assess, plan, develop and implement and evaluate a nursing program which may include on or more nursing specialties or clinics; ability to effectively apply specialized nursing skills; ability to effectively apply nursing knowledge and demonstrate proper techniques and skills in performing nursing duties; accurately observe and record symptoms, behaviors, and reactions to treatments in order to make a nursing diagnosis; respond with therapy to treatment reactions; use applicable health center automated systems to perform duties and maintain records and prepare reports; gain the cooperation of patients; analyze emergency situations and take prompt action; maintain patient confidentiality and privacy in compliance with applicable state and federal laws and regulations; maintain effective working relationships with practitioners and other health center support staff; and be sensitive to and communicate effective with patients from diverse backgrounds. Preferred Qualifications Commitment to health equity practices. Ability to work effectively and diplomatically with a diverse team. Experience in college health service or with adolescent or young adult age groups. Medical practice management experience. A Master of Science in Nursing degree. Five or more years of progressively responsible professional nursing experience is preferred. Ability to work effectively and diplomatically with a diverse team. Compensation and Benefits: Anticipated Hiring Range: $4,793 - $9,249 per month Classification Salary Range: $4,793 - $9,249 per month The salary offered will take into account internal equity and experience among other factors. The CSU system provides a comprehensive benefit package that includes medical, dental and vision plans, membership in the California Public Employees Retirement System (CalPERS), sick and vacation time, and 15 paid holidays a year. Eligible employees are also able to participate in the fee waiver education program. A summary of benefit information can be found here . Position Information: Work status: Full-time/Exempt/Probationary Academic year schedule: Monday through Friday (8:00 am - 5:00 pm), some evenings/weekends. Summer schedule: Monday through Thursday (7:00 am - 5:30 pm), some evenings/weekends. The posting has been extend and is open until filled. We will review applicant for consideration that have applied by April 9th, 2024. Afterwards, the position may close when an adequate number of qualified candidates are received. As of January 1, 2022, the CSU Out-of-State Employment Policy prohibits the hiring of employees to perform CSU-related work outside the state of California. California State University, San Bernardino in not a sponsoring agency for staff or management positions (i.e. H1-B Visas). Conditions of Employment Background Check Satisfactory completion of a background check (including a criminal records check) is required for employment. CSU will make a conditional offer of employment, which may be rescinded if the background check reveals disqualifying information, and/or it is discovered that the candidate knowingly withheld or falsified information. Failure to satisfactorily complete the background check may affect the continued employment of a current CSU employee who was conditionally offered the position. Mandated Reporter The person holding this position is considered a `mandated reporter' under the California Child Abuse and Neglect Reporting Act and is required to comply with the requirements set forth in CSU Executive Order 1083 as a condition of employment. I-9 CSUSB hires only individuals lawfully authorized to work in the United States. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification form upon hire. See Form I-9 Acceptable Documents at https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents . Statement of Commitment to Diversity In our commitment to the furthering of knowledge and fulfilling our educational mission, California State University, San Bernardino seeks a campus climate that welcomes, celebrates, and promotes respect for the entire variety of human experience. We welcome people from all backgrounds, and we seek to include knowledge and values from many cultures in the curriculum and extra-curricular life of the campus community. We will create, promote, and maintain activities and programs that further our understanding of individual and group diversity. We will also develop and communicate policies and promote values that discourage intolerance and discrimination. California State University, San Bernardino is proud to be an Affirmative Action/Equal Opportunity Employer. We recruit, hire, train, and administer all personnel actions without regard to race, ethnicity, religion, color, caste, national origin, ancestry, age, sex, gender, gender identity, gender expression, sexual orientation, socioeconomic status, genetic information, medical condition, disability, marital status, protected military or veteran status, or any other status protected by applicable law. This position adheres to CSU policies against Sex Discrimination, Sexual Harassment, and Sexual Violence, including Domestic Violence, Dating Violence, and Stalking. This requires completion of Sexual Violence Prevention Training within 6 months of assuming employment and on a two-year basis thereafter. (Executive Order 1096) For more information about Diversity & Inclusion at CSUSB, please visit https://www.csusb.edu/human-resources/diversity-inclusion Closing Statement: Reasonable Accommodation We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact CSUSB Benefits at Benefits@csusb.edu Smoking CSUSB is a smoke and tobacco-free campus. See policy at https://calstate.policystat.com/policy/6591951/latest/ . Clery Act In compliance with state and federal crime awareness and campus security legislation, including The Jeanne Clery Disclosure of Campus Security Policy and Crime Statistics Act, California Education Code section 67380, and the Higher Education Opportunity Act (HEOA), the Cal State San Bernardino Annual Security and Fire Safety Report is available at: https://www.csusb.edu/clery-act Advertised: Mar 26 2024 Pacific Daylight Time Applications close: Closing Date/Time:
CalOptima
Orange, CA, USA
Medical Case Manager (LTSS) Job Description Department(s): Long Term Care Reports to: Supervisor, Long Term Support Services FLSA status: Non-Exempt Salary Grade: L - $77,000 - $127,094 Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Thursday , February 29, 2023 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima Health Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health! About the Position The Medical Case Manager (LTSS) is part of an advanced specialty collaborative practice, responsible for case management, care coordination, authorization and utilization management of the assigned population of focus (Community Adult Based Services (CBAS), CalAIM, complex discharge and long term care (LTC) members residing in nursing facilities under custodial care) including members in the OneCare Programs, Medi-Cal only members or members living in the intermediate care facilities under regional center guidelines. The incumbent will perform utilization functions and authorizations, provide coordination of care and ongoing case management services for CalOptima Health members discharging from LTC facilities. Discharge planning may include services for CalAIM, LTC and CBAS. The incumbent will review and determine medical eligibility based on approved criteria/guidelines, National Committee for Quality Assurance (NCQA) standards, Medicare, Medi-Cal and CDA guidelines and will facilitate communication and coordination among all participants of the health care team and the member to ensure services are provided to promote quality cost-effective outcomes. The incumbent will provide intensive case management in a collaborative process that includes assessment, planning, implementation, coordination, monitoring and evaluation of the member's needs. The incumbent will be the subject matter expert and acts as a liaison to Orange County based community agencies, CalAIM program and providers, CBAS centers, In-Home Support Services (IHSS) liaisons, skilled nursing facilities, members and providers. Duties & Responsibilities: 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. Applies utilization management, authorizations and case management/nursing processes that include assessment, care planning collaboration, advocacy, implementation/intervention, monitoring and evaluation of a member's status. Performs and/or reviews clinical assessments by using CalAIM, CalOptima Health and DHCS approved standardized tools such as Pre-Admission Screening and Resident Review (PASRR), Minimum Data Set (MDS), CBAS Eligibility Determination Tool (CEDT), Health Risk Assessment (HRA), Individual Plans of Care, etc. Participates in hospital rounds. Collaborates with hospitals on complex discharges. Communicates timely with CalAIM providers and members to coordinate and initiate Community Support (CS) services and (ECM) Enhanced Case Management. Completes all documentation accurately and appropriately for data entry into the utilization management or care management system at the time of the telephone call or fax to include any authorization updates. Reviews and evaluates proposed services utilizing medical criteria, established policies and procedures, Title 22, Medicare and/or Medi-Cal guidelines. This includes review of submitted medical documentation. Determines the appropriate action regarding the service being requested for approval, modification or denial and refers to the Medical Director for review when necessary. Initiates contact with patient, family and treating physicians as needed to obtain additional information or to introduce the role of CalAIM and case management. Analyzes all requests with the objective of monitoring utilization of services, which includes medical appropriateness and identify potentially high cost, complex cases for high level case management intervention. For short-term cases, conducts a thorough and objective assessment of the member's current physical, psychosocial and environmental status and gathers all information pertinent to the case. Develops, implements and monitors a care plan through the interdisciplinary team process in conjunction with the individual member and family in internal and external settings across the continuum of care. Assesses member's status and progress routinely; if progress is static or regressive, determines reason and proactively encourages appropriate referrals to a higher level of case management or makes appropriate adjustments in the care plan, providers and/or services to promote better outcomes. Reports cost analysis, quality of care and/or quality of life improvements as measured against the case management goals. Establishes means of communication and collaboration with CalAIM providers, other team members, physicians, CBAS centers, IHSS liaisons, community agencies, health networks, skilled nursing facilities and administrators. Prepares and maintains appropriate documentation of patient care and progress within the care plan. Acts as an advocate in the member's best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals. Works collaboratively with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem-solving complex cases. Documents case notes and rationale for all decisions in the Medical Management System (i.e., JIVA, CCMS system, Altruista Guiding Care, etc). Conducts assessments by collecting in-depth information about a member's situation, identifies high-risk needs, issues and resources and gathers all information pertinent to the case to write referrals for any gaps in services. Plans and determines specific objectives, goals and actions as identified through the assessment process and makes recommendations to nursing facilities for the care of the patients. Implements by conducting specific interventions, including referring members to outside resources and/or community agencies that will result in meeting the goals established in the care plan. Supports implementation of the care plan through an interdisciplinary team process in conjunction with the member, family and all participants of the health care team. Monitors established measurable goals and routinely assesses the member's status and progress to proactively make appropriate recommendations for adjustments in the care plan, providers and/or services to promote better outcomes. Performs utilization review of services requested for members in case management by reviewing all pertinent medical records for medical necessity, applying medical review protocols and criteria and meeting the timeframes per the Utilization Management policies and procedures. Assists the Manager, Long-Term Support Services in identifying areas of needed staff training and in maintaining current data resources. Maintains confidentiality of the member's medical information. Completes other projects and duties as assigned. Experience & Education: Associate degree in nursing (ADN) required. Current, unrestricted Registered Nurse (RN) license to practice in the state of California required. 3 years of clinical experience with the health needs of the population served 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. A valid driver's license and vehicle or other approved means of transportation, an acceptable driving record and current auto insurance will be required for work away from the primary office approximately 50% of the time. Preferred Qualifications: Bachelor's degree in nursing (BSN). 2 years of experience in Long Term Care, Community Health, Managed Care Medi-Cal, Medicare programs. Active Commission for Case Manager (CCM) certification. Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese). Physical Demands and Work Environment: The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Physical demands: While performing duties of the job, employee may need to move about the organization. Employee is required to participate in provider workshops, CME events and conferences. Employee must be able to communicate, particularly for regular phone use, in meetings and face-to-face interaction. Employee must have means of transportation for offsite travel to nursing facilities approximately 95% of the time. Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. Off-site locations are equivalent to a typical physician's office, hospital, or other ancillary provider. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. Job Location: Orange, California Position Type: To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4544 Copyright 2022 Jobelephant.com Inc. All rights reserved. Posted by the FREE value-added recruitment advertising agency jeid-bf96b920096d6349b56d14901c0245fb
Medical Case Manager (LTSS) Job Description Department(s): Long Term Care Reports to: Supervisor, Long Term Support Services FLSA status: Non-Exempt Salary Grade: L - $77,000 - $127,094 Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on Thursday , February 29, 2023 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima Health Are you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health! About the Position The Medical Case Manager (LTSS) is part of an advanced specialty collaborative practice, responsible for case management, care coordination, authorization and utilization management of the assigned population of focus (Community Adult Based Services (CBAS), CalAIM, complex discharge and long term care (LTC) members residing in nursing facilities under custodial care) including members in the OneCare Programs, Medi-Cal only members or members living in the intermediate care facilities under regional center guidelines. The incumbent will perform utilization functions and authorizations, provide coordination of care and ongoing case management services for CalOptima Health members discharging from LTC facilities. Discharge planning may include services for CalAIM, LTC and CBAS. The incumbent will review and determine medical eligibility based on approved criteria/guidelines, National Committee for Quality Assurance (NCQA) standards, Medicare, Medi-Cal and CDA guidelines and will facilitate communication and coordination among all participants of the health care team and the member to ensure services are provided to promote quality cost-effective outcomes. The incumbent will provide intensive case management in a collaborative process that includes assessment, planning, implementation, coordination, monitoring and evaluation of the member's needs. The incumbent will be the subject matter expert and acts as a liaison to Orange County based community agencies, CalAIM program and providers, CBAS centers, In-Home Support Services (IHSS) liaisons, skilled nursing facilities, members and providers. Duties & Responsibilities: 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. Applies utilization management, authorizations and case management/nursing processes that include assessment, care planning collaboration, advocacy, implementation/intervention, monitoring and evaluation of a member's status. Performs and/or reviews clinical assessments by using CalAIM, CalOptima Health and DHCS approved standardized tools such as Pre-Admission Screening and Resident Review (PASRR), Minimum Data Set (MDS), CBAS Eligibility Determination Tool (CEDT), Health Risk Assessment (HRA), Individual Plans of Care, etc. Participates in hospital rounds. Collaborates with hospitals on complex discharges. Communicates timely with CalAIM providers and members to coordinate and initiate Community Support (CS) services and (ECM) Enhanced Case Management. Completes all documentation accurately and appropriately for data entry into the utilization management or care management system at the time of the telephone call or fax to include any authorization updates. Reviews and evaluates proposed services utilizing medical criteria, established policies and procedures, Title 22, Medicare and/or Medi-Cal guidelines. This includes review of submitted medical documentation. Determines the appropriate action regarding the service being requested for approval, modification or denial and refers to the Medical Director for review when necessary. Initiates contact with patient, family and treating physicians as needed to obtain additional information or to introduce the role of CalAIM and case management. Analyzes all requests with the objective of monitoring utilization of services, which includes medical appropriateness and identify potentially high cost, complex cases for high level case management intervention. For short-term cases, conducts a thorough and objective assessment of the member's current physical, psychosocial and environmental status and gathers all information pertinent to the case. Develops, implements and monitors a care plan through the interdisciplinary team process in conjunction with the individual member and family in internal and external settings across the continuum of care. Assesses member's status and progress routinely; if progress is static or regressive, determines reason and proactively encourages appropriate referrals to a higher level of case management or makes appropriate adjustments in the care plan, providers and/or services to promote better outcomes. Reports cost analysis, quality of care and/or quality of life improvements as measured against the case management goals. Establishes means of communication and collaboration with CalAIM providers, other team members, physicians, CBAS centers, IHSS liaisons, community agencies, health networks, skilled nursing facilities and administrators. Prepares and maintains appropriate documentation of patient care and progress within the care plan. Acts as an advocate in the member's best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals. Works collaboratively with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem-solving complex cases. Documents case notes and rationale for all decisions in the Medical Management System (i.e., JIVA, CCMS system, Altruista Guiding Care, etc). Conducts assessments by collecting in-depth information about a member's situation, identifies high-risk needs, issues and resources and gathers all information pertinent to the case to write referrals for any gaps in services. Plans and determines specific objectives, goals and actions as identified through the assessment process and makes recommendations to nursing facilities for the care of the patients. Implements by conducting specific interventions, including referring members to outside resources and/or community agencies that will result in meeting the goals established in the care plan. Supports implementation of the care plan through an interdisciplinary team process in conjunction with the member, family and all participants of the health care team. Monitors established measurable goals and routinely assesses the member's status and progress to proactively make appropriate recommendations for adjustments in the care plan, providers and/or services to promote better outcomes. Performs utilization review of services requested for members in case management by reviewing all pertinent medical records for medical necessity, applying medical review protocols and criteria and meeting the timeframes per the Utilization Management policies and procedures. Assists the Manager, Long-Term Support Services in identifying areas of needed staff training and in maintaining current data resources. Maintains confidentiality of the member's medical information. Completes other projects and duties as assigned. Experience & Education: Associate degree in nursing (ADN) required. Current, unrestricted Registered Nurse (RN) license to practice in the state of California required. 3 years of clinical experience with the health needs of the population served 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. A valid driver's license and vehicle or other approved means of transportation, an acceptable driving record and current auto insurance will be required for work away from the primary office approximately 50% of the time. Preferred Qualifications: Bachelor's degree in nursing (BSN). 2 years of experience in Long Term Care, Community Health, Managed Care Medi-Cal, Medicare programs. Active Commission for Case Manager (CCM) certification. Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese). Physical Demands and Work Environment: The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Physical demands: While performing duties of the job, employee may need to move about the organization. Employee is required to participate in provider workshops, CME events and conferences. Employee must be able to communicate, particularly for regular phone use, in meetings and face-to-face interaction. Employee must have means of transportation for offsite travel to nursing facilities approximately 95% of the time. Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. Off-site locations are equivalent to a typical physician's office, hospital, or other ancillary provider. About our Benefits & Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. Job Location: Orange, California Position Type: To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4544 Copyright 2022 Jobelephant.com Inc. All rights reserved. Posted by the FREE value-added recruitment advertising agency jeid-bf96b920096d6349b56d14901c0245fb