The Medical Case Manager MSSP (Multipurpose Senior Service Program) facilitates communication and coordination among the health care team to ensure services are provided to promote quality cost-effective outcomes for the member. This incumbent will provide case management interventions on behalf of older adult members living in the community with significant medical or caregiving deficits and at risk of further deterioration and/or institutionalization. Responsibilities include ensuring the medical appropriateness, quality, and cost effectiveness of proposed hospital/medical/surgical services in accordance with established criteria. The incumbent will evaluate each member as a total person and identify the functional and health limitations impeding safe independent living.
Conducts in-field assessments of each member's current status including the physical, psychosocial, and environmental.
Navigates the sensitivities of completing care management work in the private residences of members.
Builds and maintains rapport with members from diverse backgrounds to foster effective care management relationships that will support their coping with complex medical, behavioral, and social needs.
Gathers and reviews all information pertinent to each member's case, including medical documentation covering medical, health, and rehabilitation concerns. Records the information and clinical impressions.
Clinically certify level of care determinations per the California Code of Regulations, Title 22 Sections 51334 and 51335, for each eligible applicant for whom there are reasonable indications MSSP services are required and justified.
Continuously assess and communicate each member's status and progress through their participation in the program. If progress becomes static or regressive, determine cause and proactively make appropriate adjustments in the care plan, assignment of providers, and/or services to promote better outcomes.
Identifies and responds to member crisis situations by promptly prioritizing and implementing appropriate interventions.
Initiates and maintains appropriate contact with each member's family members, treating physicians, and other health care professionals to coordinate relevant information that will support the member's functioning and coping in the community.
Develop, implement, and update each member's individualize care plan through the interdisciplinary team process in conjunction with the member and family, the supervising care manager, and the MSSP social worker across the full continuum of care.
Collaborates with professionals across various disciplines involved in the member's care, including those in community agencies, with an emphasis on interpreting and problem-solving the complex barriers to the member's preferred care plan goals.
Tracks each member's quality of care and quality of life improvements, as measured against the established care plan goals.
Advocates in the member's best interest regarding the necessary benefit coverage, treatment alternatives, and access to care.
Other projects and duties as assigned.
Evaluate the quality of necessary medical services and analyze the cost of care.
Understand and abide by medical case management policies, procedures, and regulations.
Develop and maintain effective working relationships with all levels of staff, including those in other programs or agencies, and the public.
Communicate effectively in both written and verbal formats; ability to prepare clear and comprehensive reports and materials.
Utilize computers and other electronic tools as well as the software applications needed within CalOptima information systems.
Required Experience Experience & Education:
Associate's degree required; Bachelor's or higher degree preferred.
Current and unrestricted California RN license required.
Public Health Nurse (PHN) certification is preferred.
Minimum clinical experience of 5 years with the health needs of the population served, 2 years in public health with older adults preferred.
Experience in home health, hospice, or skilled nursing facility and Level of Care Certification process experience is desirable.
Case Management Certification (CCM) is desirable.
Unrestricted driver's license with an acceptable driving record and a reliable vehicle, or other approved means of transportation, will be required for the position which requires field work away from the primary office location 50% of the time or more.
Bilingual in English and in one of CalOptima's defined threshold language is preferred.
Guidelines and regulations relevant to care management and utilization management.
Confidentiality and the legal and ethical issues pertaining to case management.
Available community resources.
Effective documentation practices and guidelines.
Available medical treatments and resources.
Principles and practices of health care, health care systems, and medical administration.
Job Location Orange, California, United States Position Type Full-Time/Regular