Medical Case Manager - Orange, United States - CalOptima

CalOptima

Verified Company

Orange, United States

2 weeks ago

Posted by:

Mark Lane

beBee recruiter

Description

Medical Case Manager (Long Term Support Services)

CalOptima

Position Information:

Department
:Long Term Care:
Salary Grade
:K $70,000 $114,268 ($ $ :
Work Arrangement
:Partial Telework

This position is eligible for telework in California.

Duties & Responsibilities:

85% Medical Review Support
Participates in a missiondriven culture of highquality 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 shortterm 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 problemsolving 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 indepth information about a member's situation, identifies highrisk 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. 10%
Administrative Support
Assists the Manager, Long-Term Support Services in identifying areas of needed staff training and in maintaining current data resou