POSITION SUMMARY

Works with internal and external health care team to provide oversight of care coordination activities and promote effective and appropriate utilization of services and management of members in Case Management.

COMPLIANCE WITH REGULATIONS

Works closely with all departments necessary to ensure that the utilization management processes, programs and services are accomplished in a timely and efficient manner, in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including Centers for Medicare and Medicaid (CMS) and/or Department of Health Care Services (DHCS).

Requirements

RESPONSIBILITIES

• Conducts home visits for identified members.
• Oversight of an assigned caseload and care coordinators.
• Monitors, reviews and coordinates proposed inpatient, outpatient and specialty service requests for members in Case Management and determines covered benefits based upon lines of business benefit structures.
• Develop and maintain accurate documentation pertinent to member care coordination.
• Document all activities required in CHGNet Case Management application and QNXT Call Tracking system.
• Monitors inpatient and outpatient care and facilitates transition to the most appropriate levels of care.
• Ensures that members in Case Management have appropriate access and monitors compliance to treatment plans.
• Contribute to the team effort, maintains member confidentiality.
• Maintain company and product reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating in committees and meetings; performing other duties as required or assigned.
• Conducts necessary outreach to members in Case Management for education on compliance with prescribed treatment plans.
• Assists providers and staff in the identification of chronic care, case management and disease specific management options for identified members.
• Participates in Quality Improvement Activities (QIA) activities. Forwards quality of care concerns to the QI Department and provides case-specific follow-up for pre- determined cases.
• Researches and assists in the implementation of processes surrounding workflow and internal guideline development designed to enhance member outcomes and increase customer satisfaction.
• Attends department meetings; provides feedback for existing processes; maintains patient confidentiality; represents department in interdepartmental and external meetings and forums on request.
• Works closely with internal and external customers at assigned hospitals, clinics, and providers in order to facilitate and improve coordination of care. Provides education to members and providers on available resources. Offers assistance to peers when needed.

EDUCATION

• Graduate from an accredited school of nursing or other health-related field.
• BA degree in health-related field preferred.
• Active California RN license required or comparable credential.
• Certified Case Manager certification.

EXPERIENCE/ SKILLS

• 3 years of experience working in an acute care facility (ICU, emergency department, and/or medical/surgical unit) or outpatient health care setting and 1-year experience in a managed care environment, hospital discharge planning or outpatient clinic. Inpatient discharge planning or outpatient case management experience preferred.
• Bilingual preferred; English/Spanish, English/Tagalog, English/Arabic, English/Vietnamese.
• Knowledge of managed care principles preferred.
• Experience with understanding and interpreting clinical guidelines.
• Ability to communicate effectively verbally and in writing; exceptional telephone and customer service skills; ability to establish effective working relationships with physicians and medical professionals; ability to organize work effectively, determine priorities, and work well independently.

PHYSICAL REQUIREMENTS

• Will be required to conduct home and on-site visits.
• Valid driver’s license, working/reliable vehicle, and automobile insurance.
• Intermittent standing, walking, bending, stooping.
• Lifting 10 lb. or less.
• Driving within San Diego County to conduct home visits required (80% field, 20% office).
• May be necessary to work and attend meetings outside of facility or normal business hours.

Community Health Group has adopted a COVID-19 vaccination policy to safeguard the health and well-being of our employees. As a condition of employment, our employees are required to be fully vaccinated for COVID-19, unless a reasonable accommodation is approved or as otherwise required by law.

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.