Medical Case Manager-LTSS Emergency Department Program Job Listing at CalOptima in Orange, CA (Job ID 4219712-2024-08-06)

Description

CalOptima Health is seeking a highly motivated an experienced Medical Case Manager-LTSS Emergency Department Program to join our team. The Medical Case Manager for Long Term Services Supports (LTSS) Emergency Department Program is part of an advanced specialty collaborative practice, responsible for case management, care coordination, authorization and utilization management of the assigned population of focus (emergency department, Community Adult Based Services (CBAS), CalAIM, complex discharge and long-term care (LTC) members residing in nursing facilities under custodial care) including members in OneCare programs, Medi-Cal only members or members living in the intermediate care facilities under regional center guidelines. The incumbent will be embedded in the assigned emergency department 80-90% of the time. The incumbent will perform utilization functions and authorizations, provide coordination of care and ongoing case management services for CalOptima Health members discharging from emergency departments and LTC facilities. The incumbent will serve as the subject matter expert and act as a liaison to Orange County based community agencies, emergency departments, CalAIM program and providers, CBAS centers, Multi-purpose Senior Service Program (MSSP), In-Home Support Services (IHSS) liaisons, skilled nursing facilities, members and providers.

Position Information:

• Department: Long Term Care
• Salary Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615)
• Work Arrangement: Community Worker

Duties & Responsibilities:

• Care Management & Medical Review Support
• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• 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 the California Department of Health Care Services (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 and emergency department rounds.
• Collaborates with hospitals and emergency departments on complex discharges.
• Participates in discharge planning for CalOptima Health members that may be discharged to the community or from hospitals to nursing facilities; discharge planning may include services for CalAIM, transportation, pharmacy, primary care physician (PCP) appointments, community resources, social determinants of health (SDoH) assessments, LTC, MSSP and CBAS.
• Communicates timely with CalAIM providers and members to coordinate and initiate Community Support (CS) services and Enhanced Care Management (ECM).
• 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 short-term 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 problem-solving complex cases.
• Documents case notes and rationale for all decisions and care coordination in the Medical Management System (i.e., JIVA, etc.).
• Conducts assessments by collecting in-depth information about a member's situation, identifies high-risk 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 goals 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.
• Monitors established measurable goals and routinely assesses the member's status and progress to proactively make appropriate recommendations for adjustments in the care plan, providers and/or services to promote better outcomes.
• Performs utilization review of services requested for members in case management by reviewing all pertinent medical records for medical necessity, applying medical review protocols and criteria and meeting the timeframes per the Utilization Management policies and procedures.

Minimum Qualifications:

• Associate degree in nursing (ADN) required.
• 3 years of clinical experience with the health needs of the population served required.
• 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.
• A valid driver's license and vehicle or other approved means of transportation, an acceptable driving record and current auto insurance will be required for work away from the primary office approximately 95% of the time.

To apply and see full details, please visit: https://apptrkr.com/5487944

Compensation Information:
$90820.0 / Annually - $90820.0 / Annually