Medical Case Manager (RN)

Kinetic Personnel Group is currently recruiting a Medical Case Manager (RN) for a $3 billion-dollar a year government public health plan (government agency) is renowned for its work in the community and being a great place to work.

Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for health plan Direct members. The Medical Case Manager will facilitate communication and coordination amongst all participants of the health care team and the members to ensure that the services are provided to promote quality, cost-effective outcomes. The incumbent provides case management intervention on behalf of members with short term, stable, and predictable courses of illnesses. The incumbent is 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

• 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 evaluates proposed services utilizing medical criteria and/or established policies and procedures. This includes review of submitted medical documentation and/or photographs.
• Determines the appropriate action regarding the service being requested for approval, modification, or denial, and refer to the Medical Director for review when necessary.
• Determines if the inpatient setting requested for surgery and/or medical care is appropriate. Identifies diagnosis and determine need for continuing hospitalizations and monitor the LOS as per established guidelines and professional judgment.
• Initiates contacts with patient, family and treating physicians as needed to obtain additional information or to introduce the role of case management.
• Analyzes 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, conducts a thorough and objective assessment of the member’s status including physical, psychosocial, environmental and gather all information pertinent to the case. Develops, implements and monitors 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.
• Reports cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.
• Routinely assesses 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 makes appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
• Establishes means of communication and collaboration with other team members, physicians, community agencies, and administrators.
• Prepares and maintains appropriate documentation of patient care and progress within the care plan.
• Acts 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.
• Works collaboratively with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem and solving complex cases.
• Documents case notes and rationale for all decisions in the Guiding Care system.
• Completes other projects and duties as assigned.
• 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 public.
• Communicate clearly and concisely, both orally and in writing.
• Assess resource utilization, cost management, and negotiate effectively.
• Prepare clear, comprehensive written and oral reports and materials.
• Establish and maintain effective working relationships with Health Plan leadership and staff.
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Requirements:

• Associates degree in Nursing (ADN); or equivalent work experience required. Bachelor’s degree in Nursing (BSN) preferred.
• Current, unrestricted Registered Nurse (RN) license to practice in the State of California required.
• 3 years of clinical experience with the health needs of the population served 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.
• An active Commission for Case Manager (CCM) certification preferred.
• Guidelines and regulations relevant to case management and utilization management.
• Understand confidentiality and the legal and ethical issues pertaining to case management.

Job Types: Full-time, Contract, Temporary

Pay: $43.00 - $69.00 per hour

Expected hours: 40 per week