Summary

Job Description

Under the direct supervision of the Regulatory Lead, Case Management, the RN/LVN Case Manager is responsible to assess, plan, implement, monitor, and evaluate options and services to develop a patient focused action plan for patients. They collaborate with the primary physician and other health care team members in the development of the patient goals and action, ensuring the formulation of a realistic and definitive goal that represents the total care needs and resources of the patient and family. Facilitates the patient’s progression through the care continuum in collaboration with the health care team, the patient, and community resources.

Duties And Responsibilities

• Identifies and monitors patients with complex disease conditions and provides patient/ family education and direction within the scope of nursing practice. Works with the PCP or specialist to coordinate medical services and with transitions between levels of care and makes appropriate referrals for community services for the patient and family/ caregivers.
• Participates in data collection and analysis to support care management outcomes and identify performance improvement opportunities.
• Acts as patient advocate through the continuum and is available to the physician, patient, and family as a resource to facilitate communication. As patient advocate, he/she also monitors patient care to ensure that the patient receives quality care using the standards of care and practice guidelines.
• Performs medical, functional, safety, nutritional and psychosocial assessments on targeted assigned caseloads to evaluate the member’s needs and coordinate appropriate care.
• Documents issues, problems, appropriate interventions and follow up evaluations to be entered in a care plan based on regulatory requirements.
• Provides open, sensitive timely communication with patients, families, and their significant others to participate in the patient’s care.
• Schedules and participates in the Interdisciplinary Care Team (ICT) Meeting as they relate to his/her target cases.
• Maintains effective communication with managed care plans, physicians, hospitals, extended care facilities, members, MPM contracting department, and co-workers concerning the referral process.
• Collaborates with Social Work team to coordinate care and services for targeted case load.
• Assists in the preparation of Health Plan audits and ensure cases prepared for audits.
• Performs or assume other duties as assigned. Must show initiative.
• Assists with orientation and training for new employees as needed.
  
  

Minimum Job Requirements

• Current California RN/LVN License
• Acute Care experience, 1-2 years’ experience in Basic/ Complex Case Management a plus, 1 year experience in Managed Care. Must understand the managed care philosophy, including advanced knowledge of HMO policies and procedures and the managed care industry.
• Familiar with Case Management Policies and Procedures and its function. Must be able to manage diverse areas of understanding and interface effectively with all employees, members, employers, MPM personnel and providers.
• Must be able to triage, prioritize and identify what is urgent vs non-urgent and must be able to manage diverse areas of understanding and interface effectively with all employees, members, employers, MPM personnel and providers
  
  

Skill And Abilities

• Must be computer literate with basic office and computer skills.
• Must be detail oriented and possess strong communication skills, both verbal and written to document, assess and communicate with other staff members the plan of care which requires coordination.
• Bilingual
• EZ-CAP and ESSETTE knowledge a plus.