Job Description:Responsible for carrying out case management activities for PPO members identified through data or by Health Plan and referred to HPMG. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication and resource management and promotes quality and cost-effective interventions and outcomes. Case management activities are based on nationally recognized case management standards and concepts and principles. All contacts are telephonic.
Job Responsibilities- Collaborate with Health Plans care and disease management programs to maximize the at-risk population member's quality and manage their costs.
- Assess members' physical and psychosocial needs/barriers and develop a care plan.
- Support and encourage the use of participating Health Plan providers.
- Develop and implement the interventions needed to resolve barriers and coordinate care, allowing members to accomplish their goals with physician guidance and supervision.
- Document in Epic; assessments, care plans, interventions, and all other activity related to coordinating the care of case-managed members.
Additional Responsibilities- Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards.
- Maintain department procedure/policy standards with regard to turnaround time, etc.
- Support the interdisciplinary team approach to ensure effective resource utilization, as well as quality and cost-effective outcomes.
- Coordinate internal and external resources for the individual member.
- Maintain and update a community resource database.
- Document all case management activities in the HPMG case management online system.
- Issue letters of explanation in accordance with department policy.
- Attend and participate in in-service programs and conferences that support practice of case management.
- Perform other duties as assigned.
Required Experience- Minimum three years clinical nursing experience in an area such as medical/surgical, critical care, home health or skilled nursing, and;
- Two years of experience in case management, behavioral health, utilization management, discharge planning, and or quality improvement in a managed care setting.
- Experience with managed care delivery including IPA networks and Medicare. PPO experience preferred.
- Optimum organizational skills with ability to meet both expected and unexpected time frames.
- Excellent verbal and written communication skills.
- Ability to coordinate effectively with a variety of customers including members, providers, office staff, health plans, internal department, community resources, and peers.
- Ability to work independently with self-initiative and discipline.
- Knowledge of ICD-9 and or CPT coding.
- Working knowledge of personal computers.
Required Education- A.S. degree
- Unrestricted California Registered Nurse licensure; certification in case management preferred.
Additional InformationSalary: $100,100 - $123,000 Annual
