Job Description
Department(s): Case Management
Reports to: Manager, Case Management
FLSA status: Non-Exempt
Salary Grade: L - $37.02 - $61.10 ($77,000 - $127,094)

About CalOptima Health

CalOptima is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. If you're looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima.

About the Position

Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for CalOptima Health's members. The Medical Case Manager, High-Risk Pregnancy, will facilitate communication and coordination among all participants of the health care team and the member to ensure that the services provided promote quality, cost-effective outcomes. The incumbent will be a resource for high-risk pregnancy members, delegated plan Case Managers, Personal Care Coordinators (PCCs) and community partners to address medical, behavior and psychosocial concerns. In conjunction with other team members, the incumbent will develop and make recommendations for a comprehensive individualized care plan at all levels of care.

Duties and Responsibilities:

• 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 and analyzes member Health Risk Assessment answers and uses clinical judgment to assign a Care Management Level (CML).
• Reviews Interdisciplinary Care Team (ICT) summaries and Individual Care Plans (ICP) to ensure compliance with Centers for Medicare and Medicaid Services (CMS) and Model of Care requirements.
• Works collaboratively with the PCCs to develop care plans for members, including those who are pregnant, using member Health Risk Assessment (HRA) data.
• Utilizes all other available data to formulate care plans in the absence of an HRA.
• Ensures and facilitates communication between PCCs and delegated plan PCCs to achieve favorable member health outcomes.
• Responds appropriately to case management triggers generated as part of the HRA or ICT process.
• Anticipates needs for those at risk of transitioning of care and proactively support reducing the risk of re-entering a higher level of care.
• Acts as an integral part of the team, providing verbal and written support of member needs.
• Collaborates and communicates with the member, family, significant other(s), physicians, Health Network (HN) designee and other health care providers to support and accomplish goals identified on the individualized care plan in all care settings.
• Accepts referrals for case management and serves as a CalOptima Health's liaison to community agencies, organizations and state personnel.
• Provides case management consultation and education to members, their families and the HNs.
• Acts as an advocate to assist in the coordination of the client's identified psychosocial needs, utilizing community resources and support when appropriate.
• Participates in proactive identification of patients appropriate for care management.
• Initiates appropriate follow-up and the development of an individual care plan incorporating assessment, education, resource planning and coordination of services of those patients accepted for case management.
• Assists, as requested, to collect and analyze data from initial/annual/updated health risk assessments, stratification tools, outcome measures and internal/external reports to identify trends, individual issues, problems and resources that are most appropriate to meet client's needs.
• Develops and maintains a network of current community resources and services where members can be referred for assistance.
• Assists with the establishment of measurable standards and reporting for monitoring the OneCare Connect team's internal processes and make recommendations for areas of improvement.
• Performs regular review of cases and events to identify patterns/trends and to ensure the department's compliance with CMS, Department of Health Care Services (DHCS) and National Committee for Quality Assurance (NCQA) standards.
• Maintains documentation of case management plans/interventions and statistics required to demonstrate activities of the ICT and the impact of case management, quality and care settings that best meet the member's needs.
• Serves as a liaison and resource between CalOptima Health and the HNs departments, as applicable.
• Develops and maintains a good working relationship with all areas.
• Completes other projects and duties as assigned.

Experience & Education:

• Associates degree in Nursing (ADN) required.
• Current, unrestricted Registered Nurse (RN) license to practice in the state of California required.
• 5 years of clinical experience working with pregnancy and/or managed care experience required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Preferred Qualifications:

• Bachelor's degree in Nursing (BSN), Public Health or a related field.
• Active and unrestricted Registered Nurse CCM certificate.
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

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: While performing duties of job, employee may move about the organization. Employee must be able to sit for extended periods of time, as well as 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 regular phone use and face-to-face interaction.

• Work environment: Typical office environment with moderate noise levels and controlled office temperatures.

About our Benefits & Wellness options:

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.



Job Location: Orange, California
Position Type:

To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/4136

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