Outpatient Case Manager

Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified High Risk members. The Case Manager will assess and develop a care plan in collaboration with the admitting, attending and consulting physician, the member and other health care practitioners. The goal of the Case Manager is to effectively manage members on an outpatient basis to assure the appropriate level-of-care is provided, to prevent in patient admission and re-admissions, and ensure that the members’ medical, environmental, and psychosocial needs are met over the continuum of care.

• Keeps member/family members or other customers informed and requests if necessary, further assistance when needed.


• Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.


• Functions as liaison between administration, members, physicians and other healthcare providers.


• Interacts professionally with member/family/physicians and involves member/family/physicians in formation of the plan of care.


• Performs a Clinical Social Assessment (CSA) of the member and determines an acuity score for necessary scheduled follow-up.


• Develops an outcome-based plan of care, based on the member’s input and assessed member needs. Implements and evaluates the plan of care as often as needed as evidenced by documentation in the member’s case file.


• Documents member assessment and reassessment, member care plans, and other pertinent information completed in the member’s medical record in accordance with the FOCUS Charting methodology, nursing standards, and company policies and procedures.


• Initiates onsite hospital visits/rounds as needed to assess patient progress and meet with appropriate members of the patient care team.


• Identifies planned and unplanned transitions of care from Requests for Services or daily inpatient and SNF census.


• Educates the member/caregiver on the transition process and how to reduce unplanned transitions of care.


• Manages transition of care from the sending to receiving settings ensuring that the Plan of Care moves with the member and updates/modifies the care plan as the member’s health care status changes.


• Communicates appropriately and clearly with physicians, in patient case managers and Prior-Authorization nurses


• Identifies and addresses psychosocial needs of the members and family and facilitates consultations with Social Worker, as necessary.


• Identifies and addresses pharmacological needs of the members and facilitates consultations with the pharmacy department, as necessary.


• Identifies community resources to address needs not covered by the member’s benefit plan, and coordinates member benefits as needed, with the health plan.


• Participates in the efficient, effective and responsible use of resources such as medical supplies and equipment.


• Responsible for the coordination and facilitation of member and family conferences as determined by assessment of member’s needs.


• Prepares the necessary summary information to present to the team.


• Responsible for the coordination of post-discharge clinic appointments, medication reconciliation, PCP and SPC visits.


• Ability to collaborate and communicate with all members of the healthcare team (concurrent review, pre-authorization, PCP/SPC, Social Services, Pharmacy) to coordinate the continuum of care of developing plans for management of each case.


• Responsible for the identifying members that are appropriate for hospice conversion or Palliative care.


• Meet with members/caregiver face to face in different locations (clinic, home, hospital, and community) in order to build a rapport with member so that the case manager can better support member/caregiver with care coordination and the plan of care.

Qualifications

• Graduate from an accredited Registered Nursing Program


• Current CA RN, current CPR certification, valid CA Driver’s license.


• 3 years acute care or case management experience.


• 2-3 years of utilization or HMO experience preferred.


• Typing 40 words per minutes with accuracy.


• Knowledgeable in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint)


• On call duties as assigned.

Job Type: Full-time

Required experience:

• Emergency Room: 1 year


• Acute Care: 2 years

Required license or certification:

• Registered Nurse (RN)