Medical Case Manager (Long-Term Care)
CalOptimaCalOptima Health is seeking a highly motivated an experienced
Medical Case Manager (Long-Term Care) to join our team. The Medical Case Manager for Long Term Care (LTC) is responsible for reviewing and processing requests for authorization and notification of LTC Skilled Nursing Facilities. The incumbent will be responsible for inpatient review and referral related processes which include on-line responsibilities as well as selected off-line tasks. The incumbent utilizes CalOptima Health's medical criteria, policies and procedures to authorize referral requests from medical professionals, clinical facilities and ancillary providers. The incumbent directly interacts with provider callers and serves as a resource for their needs. The incumbent will be part of an advanced specialty collaborative practice, responsible for case management, care coordination, authorization, utilization management and discharge planning of LTC members residing in Skilled Nursing Facilities under custodial care, including members living in the Intermediate Care Facilities under Regional Center guidelines.
Position Information: - Department: Long Term Care
- Salary Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615)
- Work Arrangement: Partial Telework
**This position is eligible for telework in California.**
Duties & Responsibilities: - 95% - Program 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.
- Reviews requests for medical appropriateness for inpatient services utilizing medical criteria and/or established policies and procedures.
- Performs and/or reviews clinical assessments by using CalOptima Health and California Department of Health Care Services (DHCS) approved standardized tools such as Pre-Admission Screening and Resident Review (PASRR), Minimum Data Set (MDS), Individual Plans of Care, etc.
- Verifies and processes specialty referrals, Hospice General Inpatient, durable medical equipment and supplies via telephone or fax by using established clinical protocols to determine medical necessity.
- Screens inpatient requests for Medical Director review, gathers pertinent medical information prior to submission to the Medical Director; follows up with the requester by communicating the Medical Director's decision; documents follow-up in the utilization management system.
- 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, skilled nursing facility and treating physicians as needed to obtain additional information.
- Analyzes all requests with the objective of monitoring utilization of services, which includes reviewing for medical appropriateness and identifying potentially high cost complex cases requiring high-level case management intervention.
- Applies utilization management, authorizations, case management/nursing processes that include assessment, care planning collaboration, advocacy, implementation/intervention, monitoring and evaluation of a member's status.
- 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, Community Based Adult Services (CBAS) centers, In-Home Support Services (IHSS) liaisons, community agencies, health networks, skilled nursing facilities and administrators.
- Acts as an advocate in the member's best interest for necessary funding, treatment alternatives, timelines, 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.
- Meets productivity and quality of work standards on an ongoing basis.
- 5% - Completes other projects and duties as assigned.
Minimum Qualifications: - Associate degree in nursing (ADN) required PLUS 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.
Preferred Qualifications: - Bachelor of Science in Nursing (BSN) preferred.
- 3 years of experience in Title 22, Medi-Cal and/or Medicare programs.
- 1 year of authorization review (in-patient skilled nursing facility) experience.
- 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).
Required Licensure / Certifications: - Current, unrestricted Registered Nurse (RN) license to practice in the state of California required.
- 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.
Knowledge & Abilities:
- 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.
Physical Requirements (With or Without Accommodations): - 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 Environment:If located at the 500, 505 Building or a remote work location:
- 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.
If located at PACE:
- 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.
If located in the Community:
- 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.
About CalOptima Health:
CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay!
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 Monday or 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. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the
2024 CalOptima Health Benefits Guide regarding our comprehensive benefits and wellness package.
IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONSApplications 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
September 6, 2024 at 9:00 PM (PST). 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. The selection process may include, but is not limited to, a skills assessment, phone screen and interview.The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet.
Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application.
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 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 at (714) 246-8400 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.To apply, please visit: https://jobs.caloptima.org/jobs/medical-case-manager-long-term-care-505-city-parkway-west-california-united-states
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