Primary Purpose:
To provide support and facilitate care of members who require case management. To work collaboratively with Health Plan and Hospital Case Management Departments in the facilitation of services. To collaborate with the treating physician and IPA Medical Director in the review and decision-making process regarding the facilitation of appropriate health care and service requests. Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes. If applicable, the CM will coordinate care for Cal Medi-Connect program members to ensure all aspects of the CMC program description are implemented and followed. A case manager is a licensed LVN. A care manager can be a licensed social worker (MSW) or licensed nurse (LVN). NEW GRADS WELCOME!
All candidates for any case management position will have the appropriate education and experience to meet requirements and the service needs of the populations.
Principal Duties and Responsibilities (* = essential functions):
· To utilize the Case Management functions: assessor, planner, facilitator, advocate. *
· To facilitate services at the appropriate Health Plan center of excellence.
· To review and process clinical information in accordance with regulatory mandates to facilitate patient healthcare and services across the continuum of care. *
· To interface professionally and courteously with all internal staff and external customers to ensure appropriate exchange of information. *
· To prepare and participate in health plan audits onsite as required.
· To actively participate in Utilization Management Committees in regard to Case Presentations and problem- solving.
· To participate in the development of Case Management Policies and Procedures.
· To actively participate in the discharge planning process. *
· To monitor and participate in the SNP/Duals program
· To ensure all members are living in the least restrictive environment
· To follow the UM/QI/CM/SNP/CMC program descriptions
· To perform other duties as assigned.
Job Specifications (KSAs):
Requires extensive and specialized knowledge of utilization and case management processes, as is generally acquired by 1 year or greater of experience as a case manager in a Managed Care Environment, and successful completion of a nursing program.Requires prior Case Management experience, preferably with catastrophic cases.Requires an active LVN license in the state of California. Requires excellent written and verbal communication skills.Requires computer experience, particularly Microsoft Word, Excel, familiarity with Cozeva or EZCap, a plus, and the ability to learn new software applications quickly.Requires problem-solving and critical thinking skills.Requires professional demeanor and the ability to contribute to a positive work environment.Requires extensive knowledge of health plan guidelines.Position Performance Criteria:
1. Demonstrates proficiency in UM and Case Management, including but not limited to:
Referral reviewConcurrent/inpatient review and bed-day management.2. Demonstrates the effective practice of Case Management Standards of Care, including:
AssessmentCase Identification and SelectionPlanningMonitoringEvaluating Outcomes3. Sets appropriate priorities to meet departmental goals and objectives, including but not limited to:
Demonstrates ability to efficiently manage case load.Demonstrates ability to set appropriate prioritiesConsistently renders prudent and sound decisionsManages multiple tasks while meeting required timeframesAdheres to departmental policies and procedures4. Demonstrates knowledge of Health Plan guidelines.
5. Consistently demonstrates professional work ethic, collegial interaction with others, and reliability, while contributing to a positive work environment, including but not limited to:
· Professional appearance and demeanor
· Meets departmental attendance needs on-site
· Participates verbally in group activities, i.e., staff meetings, etc.
· Demonstrates respect for co-workers and customers.
· Works collaboratively with other departments to identify and resolve issues.
Primary Purpose:
To provide support and facilitate care for members who require case management. To work collaboratively with the Health Plan and Hospital Case Management Departments to facilitate services. To collaborate with the treating physician and IPA Medical Director in the review and decision-making process regarding the provision of appropriate health care and service requests. Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates an individual’s health needs through communication and available resources to promote quality and cost-effective outcomes.
The CM will coordinate care for Cal Medi-Connect program members to ensure that all aspects of the DSNP program description are implemented and followed.
All services under Medicare and Medi-Cal will be coordinated and monitored, including CCS, IHSS, CBAS, and BH. The case manager is a licensed nurse (RN or LVN). A care manager can be a licensed social worker (MSW) or a licensed nurse (RN or LVN).
All candidates for any position within case management will have the appropriate education and experience to meet requirements and the service needs of the population.
Principal Duties and Responsibilities (* = essential functions):
To utilize the Case Management functions: assessor, planner, facilitator, and advocate. *To facilitate services at the appropriate Health Plan center of excellence. *To review and process clinical information in accordance with regulatory mandates to facilitate patient healthcare and services across the continuum of care. *To perform case management as appropriate to the patient’s medical condition and healthcare needs, utilizing the standards of practice for Case Management.To interface professionally and courteously with all internal staff and external customers to ensure appropriate exchange of information. *Preparing for and participating in health plan audits as required.To actively participate in Utilization Management meetings regarding Case Presentations and problem-solving.To participate in the development of Case Management Policies and Procedures.To actively participate in the discharge planning process.To monitor and participate in the SNP/Duals programTo follow the UM/QI/CM/SNP/CMC program descriptions To perform other duties as assigned.
Job Specifications (KSAs):
Requires extensive and specialized knowledge of utilization and case management processes, generally acquired through 2-3 years or more of experience as a case manager in a Managed Care Environment, or through successful completion of a nursing program.Requires prior Case Management experienceRequires an active RN or LVN license in the state of employment.Requires clinical expertise, generally acquired through 3 to 5 years of acute nursing practice.Requires excellent written and verbal communication skills.Requires computer experience, particularly with Microsoft Word and Excel, familiarity with Cozeva (a plus), and the ability to learn new software applications quickly.Requires problem-solving and critical thinking skills.Requires professional demeanor and the ability to contribute to a positive work environment.Requires knowledge of regulatory standards such as Medicare, TitleXXII, and Medi-Cal*Requires extensive knowledge of health plan guidelines.Position Performance Criteria:
Demonstrates proficiency in UM and Case Management, including but not limited to:Complex Case ManagementTransplant ManagementReferral reviewOut-of-network managementDemonstrates the effective practice of Case Management Standards of Care, including: AssessmentCase Identification and SelectionPlanningMonitoringEvaluating OutcomesSets appropriate priorities to meet departmental goals and objectives, including but not limited to:Demonstrates ability to efficiently manage case load.Demonstrates ability to set appropriate prioritiesConsistently makes prudent and sound decisionsManages multiple tasks while meeting required timeframesAdheres to departmental policies and proceduresDemonstrate knowledge of Health Plan guidelines.Demonstrates knowledge of federal, state, NCQA, and health plan regulatory requirements and approved criteria guidelines.Ensures consistency in the application of the utilization process.Maintains knowledge of new legislation and disseminates information to providers and co-workers.Demonstrates ability to give concise, articulate, and accurate case presentations to Medical Director, UMC, etc., including problem-solving.Consistently demonstrates professional work ethic, collegial interaction with others, and reliability, while contributing to a positive work environment, including but not limited to:Professional appearance and demeanorMeets departmental attendance needs on siteParticipates verbally in group activities, i.e., staff meetings, etc.Demonstrates respect for co-workers and customers.Works collaboratively with other departments to identify and resolve issues. Read LessPrimary Purpose:
Data input of referral authorization requests received from the Organization's Contracted Providers; generate member notifications as directed.
Principal Duties and Responsibilities (* = essential functions):
Verifies eligibility and benefits for each referral. *Performs data entry of referral authorization requests for primary care visits, specialty consults, diagnostic/outpatient procedures, and admissions approved by the Medical Director. *Tracks and monitors progress of referral requests, responding to requests for additional information to assist the medical director's staff in making a decision. *Primary telephone call process for incoming calls into the Utilization Management Department. *Provides referral and authorization notifications to providers as directed. *Organizes and maintains electronic and hard copy filing systems for authorizations/referrals as directed. Prepares assigned correspondence and reports and complies with statistical data as directed. Tracks all types of references on the computer system on a hard copy log and compiles statistics monthly. Supports and facilitates teamwork within the department/group and the organization. Obtains CPT procedure codes and ICD-10 diagnosis codes from referring providers to assist with the determination of approval/denial. Ensures that network providers are utilized. Handles incoming calls from physicians, ancillary providers, and patients regarding referral authorization requests. Review file for completeness of required documentation, including but not limited to confirmation of receipt of notification copies of written notification correspondence with members and providers. Monitors and facilitates requisition requests for home health DME and other services in accordance with benefit guidelines. Coordinates all out-of-network outpatient specialist referrals with the Medical Director. Generates all required letters and notifications to patients and providers regarding referral authorizations, medical approval, and medical denial within established timeframes in accordance with policies, procedures, and contractual requirements. Provide the requested information during the appeals process. To organize and act promptly on pending denial files/cases to maintain designated turnaround times and physician communication. To provide information to licensed nursing staff regarding referrals that are 'not a covered benefit' and facilitate denial letters. To organize, manage, and prioritize workload effectively to process authorization request forms within the established time frame. *To refer appropriate authorization request forms to the IPA case manager based on established criteria. To educate and inform physicians and their office staff of any changes to the referral process, network changes, or other information about the referral process. Assist other departments in creating denial documentation during the appeals process. Document denial and denial rationale in data management systems. *Maintains/updates all required reporting for referrals/authorizations.Complete other duties and special projects as assigned. Ensure all required work is completed on time by the end of each shift. Participates in scheduled departmental/group meetings. Represents the department/group and organization professionally and positively. To perform other duties as assigned.Job Specifications (KSAs):
Six months of experience in the medical field, either in a hospital, clinical, or insurance setting, that includes experience with computers.The ability to read, write, and speak English and perform other basic educational skills, as is generally obtained by completing High school or a GED equivalent.Bilingual English/Spanish preferred.Clear and accurate knowledge of medical terminology; managed care experience and knowledge preferred.Working knowledge & expertise of ICD-10 & CPT-4 codes.Demonstrated computer literacy. Excel experience helpful.Excellent communication skills in both oral and written modes, as well as superior telephone etiquette.Excellent Customer Service experience and proficiency required.Pay Range $18 - $27.00 hourly DOE.
