RN Case Manager Medical Review

$77,854 - $124,571/Yr

All's Well Health Care - Orange, CA

Full-time - Mid Level

Orange, CA

Administrative and Support Services

About the position

The Medical Case Manager will be responsible for case management, care coordination, authorization, and utilization management for a specific population, including members in Community Based Adult Services (CBAS), CalAIM, and long-term care. This role requires collaboration with various healthcare providers and facilities to ensure high-quality care and support for members, focusing on their individual needs and goals.

Responsibilities

• Participate in a mission-driven culture of high-quality performance, focusing on customer service, consistency, dignity, and accountability.
• Assist the team in carrying out department responsibilities and collaborate to support short- and long-term goals/priorities.
• Apply utilization management, authorizations, and case management/nursing processes, including assessment, care planning, collaboration, advocacy, implementation/intervention, monitoring, and evaluation of a member's status.
• Perform and/or review clinical assessments using CalAIM and DHCS approved standardized tools such as PASRR, MDS, CEDT, HRA, and Individual Plans of Care.
• Participate in hospital rounds and collaborate with hospitals on complex discharges.
• Communicate timely with CalAIM providers and members to coordinate and initiate Community Support (CS) services and Enhanced Case Management (ECM).
• Complete 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, including any authorization updates.
• Review and evaluate proposed services using medical criteria, established policies and procedures, Title 22, Medicare, and/or Medi-Cal guidelines, including review of submitted medical documentation.
• Determine the appropriate action regarding the service being requested for approval, modification, or denial and refer to the Medical Director for review when necessary.
• Initiate contact with patients, families, and treating physicians as needed to obtain additional information or introduce the role of CalAIM and case management.
• Analyze all requests with the objective of monitoring utilization of services, including medical appropriateness, and identify potentially high-cost, complex cases for high-level case management intervention.
• Conduct thorough and objective assessments of the member's current physical, psychosocial, and environmental status for short-term cases.
• Develop, implement, and monitor a care plan through the interdisciplinary team process in conjunction with the individual member and family across the continuum of care.
• Routinely assess member's status and progress; if progress is static or regressive, determine the reason and proactively encourage appropriate referrals or make adjustments in the care plan, providers, and/or services to promote better outcomes.
• Report cost analysis, quality of care, and/or quality of life improvements as measured against the case management goals.
• Establish 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.
• Prepare and maintain appropriate documentation of patient care and progress within the care plan.
• Act as an advocate in the member's best interest for necessary funding, treatment alternatives, timelines, and coordination of care with frequent evaluations of progress and goals.
• Work collaboratively with staff members from various disciplines involved in patient care, emphasizing interpreting and problem-solving complex cases.
• Document case notes and rationale for all decisions in the Medical Management System (e.g., JIVA, CCMS system, Altruista Guiding Care).
• Conduct assessments by collecting in-depth information about a member's situation, identifying high-risk needs, issues, and resources, and writing referrals for any gaps in services.
• Plan and determine specific objectives, goals, and actions as identified through the assessment process and make recommendations to nursing facilities for patient care.
• Implement specific interventions, including referring members to outside resources and/or community agencies to meet the goals established in the care plan.
• Support implementation of the care plan through an interdisciplinary team process in conjunction with the member, family, and all participants of the health care team.
• Monitor established measurable goals and routinely assess the member's status and progress to make appropriate recommendations for adjustments in the care plan, providers, and/or services to promote better outcomes.
• Perform 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.

Requirements

• 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.
• 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.

Nice-to-haves

• 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 one of defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

Benefits

• Competitive hourly pay ranging from $37.43 to $59.89.
• Full-time contract position with a Monday to Friday schedule.