Travel Nurse RN - Case Manager - $2,149 per week in Orange, CA

Company: talent4health
Location: Orange
Posted on: February 9, 2025

Job Description:

CalOptima Health is seeking a highly motivated an experienced TEMP - Medical Case Manager - LTSS (2) to join our team. The Medical Case Manager (LTSS) is part of an advanced specialty collaborative practice, responsible for case management, care coordination, authorization and utilization management of the assigned population of focus (Community Based Adult Services (CBAS), CalAIM, complex discharge and long term care (LTC) members residing in nursing facilities under custodial care) including members in the OneCare Programs, Medi-Cal only members or members living in the intermediate care facilities under regional center guidelines. The incumbent will perform utilization functions and authorizations, provide coordination of care and ongoing case management services for CalOptima Health members discharging from LTC facilities. Discharge planning may include services for CalAIM, LTC and CBAS. The incumbent will review and determine medical eligibility based on approved criteria/guidelines, National Committee for Quality Assurance (NCQA) standards, Medicare, Medi-Cal and CDA guidelines and will facilitate 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 will provide intensive case management in a collaborative process that includes assessment, planning, implementation, coordination, monitoring and evaluation of the member---s needs. The incumbent will be the subject matter expert and acts as a liaison to Orange County based community agencies, CalAIM program and providers, CBAS centers, In-Home Support Services (IHSS) liaisons, skilled nursing facilities, members and providers. Position Information: - Department: Long Term Care - Salary Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615) - Work Arrangement: Full Office Duties & Responsibilities: - 85% - Medical Review Support 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. Applies utilization management, authorizations and case management/nursing processes that include assessment, care planning collaboration, advocacy, implementation/intervention, monitoring and evaluation of a member---s status. Performs and/or reviews clinical assessments by using CalAIM, CalOptima Health and DHCS approved standardized tools such as Pre-Admission Screening and Resident Review (PASRR), Minimum Data Set (MDS), CBAS Eligibility Determination Tool (CEDT), Health Risk Assessment (HRA), Individual Plans of Care, etc. Participates in hospital rounds. Collaborates with hospitals on complex discharges. Communicates timely with CalAIM providers and members to coordinate and initiate Community Support (CS) services and (ECM) Enhanced Case Management. Completes all documentation accurately and appropriately for data entry into the utilization management or care management system at the time of the telephone call or fax to include any authorization updates. Reviews and evaluates proposed services utilizing medical criteria, established policies and procedures, Title 22, Medicare and/or Medi-Cal guidelines. This includes review of submitted medical documentation. Determines the appropriate action regarding the service being requested for approval, modification or denial and refers to the Medical Director for review when necessary. Initiates contact with patient, family and treating physicians as needed to obtain additional information or to introduce the role of CalAIM and 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 current physical, psychosocial and environmental status and gathers 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. Assesses member---s status and progress routinely; if progress is static or regressive, determines reason and proactively encourages appropriate referrals to a higher level of case management or makes appropriate adjustments in the care plan, providers and/or services to promote better outcomes. Reports cost analysis, quality of care and/or quality of life improvements as measured against the case management goals. Establishes means of communication and collaboration with CalAIM providers, other team members, physicians, CBAS centers, IHSS liaisons, community agencies, health networks, skilled nursing facilities and administrators. Prepares and maintains appropriate documentation of patient care and progress within the care plan. Acts 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. Works collaboratively with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem-solving complex cases. Documents case notes and rationale for all decisions in the Medical Management System (i.e., JIVA, CCMS system, Altruista Guiding Care, etc). Conducts assessments by collecting in-depth information about a member---s situation, identifies high-risk needs, issues and resources and gathers all information pertinent to the case to write referrals for any gaps in services. Plans and determines specific objectives, goals and actions as identified through the assessment process and makes recommendations to nursing facilities for the care of the patients. Implements by conducting specific interventions, including referring members to outside resources and/or community agencies that will result in meeting the goals established in the care plan. Supports implementation of the care plan through an interdisciplinary team process in conjunction with the member, family and all participants of the health care team. Monitors established measurable goals and routinely assesses the member---s status and progress to proactively make appropriate recommendations for adjustments in the care plan, providers and/or services to promote better outcomes. Performs utilization review of services requested for members 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. - 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. - Applies utilization management, authorizations and case management/nursing processes that include assessment, care planning collaboration, advocacy, implementation/intervention, monitoring and evaluation of a member---s status. - Performs and/or reviews clinical assessments by using CalAIM, CalOptima Health and DHCS approved standardized tools such as Pre-Admission Screening and Resident Review (PASRR), Minimum Data Set (MDS), CBAS Eligibility Determination Tool (CEDT), Health Risk Assessment (HRA), Individual Plans of Care, etc. - Participates in hospital rounds. - Collaborates with hospitals on complex discharges. - Communicates timely with CalAIM providers and members to coordinate and initiate Community Support (CS) services and (ECM) Enhanced Case Management. - Completes all documentation accurately and appropriately for data entry into the utilization management or care management system at the time of the telephone call or fax to include any authorization updates. - Reviews and evaluates proposed services utilizing medical criteria, established policies and procedures, Title 22, Medicare and/or Medi-Cal guidelines. This includes review of submitted medical documentation. - Determines the appropriate action regarding the service being requested for approval, modification or denial and refers to the Medical Director for review when necessary. - Initiates contact with patient, family and treating physicians as needed to obtain additional information or to introduce the role of CalAIM and 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 current physical, psychosocial and environmental status and gathers 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. - Assesses member---s status and progress routinely; if progress is static or regressive, determines reason and proactively encourages appropriate referrals to a higher level of case management or makes appropriate adjustments in the care plan, providers and/or services to promote better outcomes. - Reports cost analysis, quality of care and/or quality of life improvements as measured against the case management goals. - Establishes means of communication and collaboration with CalAIM providers, other team members, physicians, CBAS centers, IHSS liaisons, community agencies, health networks, skilled nursing facilities and administrators.

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