Medical Case Manager PA

Decton Staffing Services


$26.00-42.00/H DOE


Job SummaryCase Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for Company Direct members. The position will facilitate communication and coordination amongst all participants of the health care team and the member to ensure that the services are provided to promote quality, cost-effective outcomes. This position provides case management intervention on behalf of members with short term, stable, and predictable courses of illnesses. Also responsible for answering the medical appropriateness, quality, and cost effectiveness of proposed hospital/medical/surgical services in accordance with established criteria. This activity may be conducted prospectively, concurrently, or retrospectively.

Position Responsibilities

  • Review and evaluate proposed services utilizing medical criteria and/or established policies and procedures. 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.
  • Determine if the inpatient setting requested for surgery and/or medical care is appropriate. Identify diagnosis and determine need for continuing hospitalizations and monitor the LOS as per established guidelines and professional judgment.
  • Initiate contacts 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 status including physical, psychosocial, environmental, 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.
  • Report cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.
  • Routinely assess member’s status and progress; if progress is static or regressive determine reason and proactively encourage appropriate referrals to higher level of case management or make appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
    • Establish means of communication and collaboration with other team members, physicians, community agencies, and administrators.
    • Prepare and maintain appropriate documentation of patient care and progress within the care plan.
    • Act as an advocate in the client’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
    • Work collaboratively with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem and solving complex cases.
    • Document case notes and rationale for all decisions in the Guiding Care system.
    • Other projects and duties as assigned.

Possess the Ability To:

  • Evaluate the quality of necessary medical services, and be able to acquire and analyze the cost of care.
  • Assist in the formulation of medical case management policies and procedures; understand and interpret policies, procedures and regulations.
  • Develop and maintain effective working relationships with all levels of staff, other programs, agencies, and the general public.
  • Communicate effectively at all organizational levels and in situations requiring instructing, persuading, negotiating, consulting, and advising.
  • Assess resource utilization, cost management and negotiate effectively.
  • Prepare clear, comprehensive written and oral reports and materials.
  • Effectively utilize computer and appropriate software and interact as needed with company Information Services.

Experience & Education

  • Bachelor’s degree in Nursing or related field; or equivalent work experience required.
  • Current LVN license to practice in the State of California is required.
  • 3+ years minimum clinical experience with the health needs of the population served required.
  • An 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-9/ICD-10 and CPT coding requirements.
  • 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.
  • Computers, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Physical Demands and Work Environment

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Physical demands:  Employee must be able to sit for extended periods of time and work at the computer for long periods.  Employee is required to use hands and fingers, especially for typing on the computer and using the mouse.  Employee must be able to communicate, particularly for frequent phone use and face-to-face interaction.
  • Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures.




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