Medical Case Manager

Decton Staffing Services

Decton Inc. is currently recruting for a company in Orange, CA! Currently seeking an RN Case Manager. If qualified, please submit your resume and contact Liz directly (949)421-6006.


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.  The incumbent performs utilization functions, provides coordination of care, and provides ongoing case management services for members discharging from Long Term Care (LTC) facilities. Discharge planning may include services for Community Based Adult Services (CBAS) and/or In-Home Support Services (IHSS) post-discharge.  The incumbent reviews and determines medical eligibility based on approved criteria/guidelines, NCQA standards, Medicare and Medi-Cal guidelines, and facilitates communication and coordination among all participants of the health care team and the member to ensure services are provided to promote quality, cost-effective outcomes.  The incumbent provides intensive case management in a collaborative process that includes assessment, planning, implementation, coordination, monitoring and evaluation of the member’s needs.  The incumbent is the subject matter expert and acts as a liaison to Orange County based community agencies, CBAS centers, IHSS Liaisons, skilled nursing facilities, and to members and providers.    

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.
  • Establish means of communication and collaboration with other team members, physicians, CBAS centers, IHSS Liaisons, community agencies, health networks, skilled nursing facilities, and administrators.
  • Prepare and maintain appropriate documentation of patient care and progress within the care plan.
  • Act 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.
  • Work collaboratively with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem solving complex cases.
  • Document case notes and rationale for all decisions in the Medical Management System (i.e. CCMS system, Altruista Guiding Care, etc).
  • Assessment collect in-depth information about a member’s situation, identify high-risk needs, issues, resources and gather all information pertinent to the case in order to develop a comprehensive care plan to meet those needs.
  • Planning determine specific objectives, goals and actions as identified through the assessment process. The comprehensive care plan will be action oriented, time specific and be applied across a continuum of care for the individual member.
  • Implementation- conduct specific interventions, including referring members to outside resources and/or community agencies that will result in meeting the goals established in the care plan.
  • Implement the care plan through an interdisciplinary team process in conjunction with the member, family and all participants of the health care team.
  • Monitoring established measurable goals and routinely assesses the member’s status and progress in order to proactively make appropriate adjustments in the care plan, providers and/or services to promote better outcomes.        
  • May perform utilization review of services requested for members that are 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.
  • Assist the LTSS Manager in identifying areas of staff training needed and in maintaining current date resources.

Experience & Education

  • Current and extensive knowledge of the NCQA, Title 22, Medi-Cal, Medicare and CalOptima 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.
  • 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.
  • Bilingual in English and one of CalOptima’s defined threshold languages 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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