Medical Case Manager, Community Based Adult Services

Duties & Responsibilities:

• 95% - Medical Review Support
• Participates in a mission-driven culture of high-quality 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.
• Reviews requests for medical appropriateness for CBAS services utilizing Medi-Cal criteria or established policies and procedures.
• Performs and/or reviews clinical assessments including California Department of Aging (CDA) approved standardized tools such as CBAS Eligibility Determination Tool (CEDT) and CBAS Individual Plan of Care (IPC).
• Determines the appropriate decision regarding the service being requested for approval, modification or denial, and refers to the Medical Director when necessary.
• Screens CBAS requests for Medical Director review, gathers pertinent medical information prior to submission to the Medical Director, communicates the Medical Director’s decision with the requestor and documents follow-up in the care management system.
• Initiates and follows through with contacting the member’s caregiver, family, CBAS provider and treating physician as needed to obtain additional information for utilization review.
• Complete all documentation accurately and appropriately for data entry in the care management system during authorization review, assessment and communication to include any authorization updates.
• Accurately codes each diagnosis of service and procedures according to the established policy and procedure.
• Analyzes all requests with the objective of monitoring utilization of services, which includes reviewing for medical appropriateness and identifying potentially high-cost complex cases requiring high-level case management intervention.
• Establishes a means of communication with other team members, Medical Directors, community support providers including CalAIM and IHSS, and skilled nursing facilities.
• Meets identified productivity and quality of work standards on an ongoing basis.

• 5% - Other
• Completes other projects and duties as assigned.

Minimum Qualifications:

• Associate degree in Nursing (ADN) PLUS 3 years of nursing experience with the health needs of the population served; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

Preferred Qualifications:

• 1 year of authorization review experience.

• Bilingual in English and in one of CalOptima Health’s defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).

Required Licensure / Certifications:

• Current unrestricted Registered Nurse (RN) license to practice in the state of California required.

Knowledge & Abilities:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

Pay: From $42.71 per hour

Work Location: In person