Medical Case Manager

Decton Staffing Services

Decton Inc. is currently recruting for a company in Orange, CA! Currently seeking a RN Case Manager. If qualified, please submit your resume and apply to this post. You may contact Liz directly (949)421-6006 (Call or Text)


Job Summary

The Medical Case Manager (Long Term Care) (LTC) is part of an advanced specialty collaborative practice, responsible for case management, care coordination and utilization management of the assigned population (Members residing in LTC Nursing Facilities under custodial care) including members in the OneCare Connect or OneCare Programs, Medi-Cal only members or members living in the Intermediate Care Facilities under Regional Center guidelines. 

Position Responsibilities

  • Apply case management/nursing processes that include assessment, care planning collaboration, advocacy, implementation/intervention, monitoring and evaluation of a member’s status.
  • Perform and/or review clinical assessments by using approved standardized tools such as Pre-Admission Screening and Resident Review (PASSAR), Minimum Data Set (MDS), CBAS Eligibility Determination Tool (CEDT), Health Risk Assessment (HRA), Individual Plans of Care, etc.
  • Receive reviews, verify and process requests for referrals, diagnostic testing, inpatient admissions, outpatient procedures/testing, emergency room notification, home health care services, and durable medical equipment and supplies via telephone or fax.
  • Complete all documentation accurately and appropriately for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates.
  • Review and evaluate proposed services utilizing medical criteria, established policies and procedures, Title 22, Medicare and/or Medi-Cal guidelines.  This includes review of submitted medical documentation and/or photographs.
  • Determine the appropriate action with regard to the service being requested for approval, modification or denial, and refer to the Medical Director for review when necessary.
  • Initiate contact with patient, family, and treating physicians as needed to obtain additional information or to introduce the role of case management.
  • Analyze 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, conduct a thorough and objective assessment of the member’s current physical, psychosocial and environmental status, and gather all information pertinent to the case.  Develop, implement and monitor 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.
  • Routinely assess member’s status and progress; if progress is static or regressive, determine reason and proactively encourage appropriate referrals to a higher level of case management or make appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
  • Report cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.

Experience & Education

  • Current and extensive knowledge of the NCQA, Title 22, Medi-Cal, Medicare and  programs is preferred.
  • Current, unrestricted RN license to practice in the State of California is required.
  • Degree in Nursing or license that permits independent practice without the supervision of another licensed professional.
  • 3+ years of clinical experience with the health needs of the population served, and extensive experience at an increasingly responsible professional level that is directly related to the knowledge and abilities listed is required.
  • Active CCM certification is preferred.

Knowledge of:

  • Guidelines and regulations relevant to case management and utilization management.
  • Understand confidentiality and the legal and ethical issues pertaining to case management.
  • ICD-10 and CPT coding, requirements for prior approval.
  • Available community resources.
  • Effective charting practices and guidelines.
  • Available medical treatments and resources.
  • Principles and practices of health care, health care systems, and medical administration.
  • Personal computers, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
  • Hospice, Long term services and supports such as nursing facility admission criteria, Community Adult Based Services (CBAS), In-Home Supportive Services (IHSS), and/or Multipurpose Senior Services Program (MSSP) benefits. 
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