Clinical Services Nurse

PHYSICIANS DATA TRUST•Los Angeles, CA

5d•$34 - $45•Onsite

About The Position

To provide support and facilitate care for members who require case management. To work collaboratively with the Health Plan and Hospital Case Management Departments to facilitate services. To collaborate with the treating physician and IPA Medical Director in reviewing and deciding on the provision of appropriate health care and service requests. Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates an individual’s health needs through communication and available resources to promote quality and cost-effective outcomes. If applicable, the CM will coordinate care for Cal Medi-Connect program members to ensure that all aspects of the CMC program description are implemented and followed. All Medicare and Medi-Cal services will be coordinated and monitored, including CCS, IHSS, CBAS, and BH. The case manager is a licensed nurse (RN or LVN). A care manager can be a licensed social worker (MSW) or a licensed nurse (RN or LVN). All candidates for any position within case management will have the appropriate education and experience to meet requirements and the service needs of the population.

Requirements

Requires extensive and specialized knowledge of utilization and case management processes, generally acquired through 2-3 years or more of experience as a case manager in a Managed Care Environment, or through successful completion of a nursing program.
Requires prior Case Management experience, preferably with catastrophic cases.
Requires an active RN or LVN license in the state of employment.
Requires clinical expertise, generally acquired through 3 to 5 years of acute nursing practice.
Requires excellent written and verbal communication skills.
Requires computer experience, particularly with Microsoft Word and Excel, familiarity with Cozeva (a plus), and the ability to learn new software applications quickly.
Requires problem-solving and critical thinking skills.
Requires professional demeanor and the ability to contribute to a positive work environment.
Requires knowledge of regulatory standards such as Medicare, Title XXII, and Medi-Cal.
Requires extensive knowledge of health plan guidelines.

Nice To Haves

Familiarity with Cozeva

Responsibilities

Utilize the Case Management functions: assessor, planner, facilitator, advocate.
Facilitate services at the appropriate Health Plan center of excellence.
Utilize the most cost-effective case rates and contracts.
Review and process clinical information in accordance with regulatory mandates to support patient healthcare and services across the continuum of care.
Perform catastrophic case management as appropriate to the patient’s medical condition and healthcare needs, utilizing the standards of practice for Case Management.
Interface professionally and courteously with all internal staff and external customers to ensure appropriate exchange of information.
Prepare for and participate in onsite health plan audits as required.
Actively participate in Utilization Management Committees regarding Case Presentations and problem-solving.
Participate in the development of Case Management Policies and Procedures.
Actively participate in the discharge planning process.
Monitor and participate in the SNP/Duals program.
Monitor and participate in the CMC program.
Ensure all members are living in the least restrictive environment.
Follow the UM/QI/CM/SNP/CMC program descriptions.
Assigned to On-Call after-hours Customer Service Care.
Perform other duties as assigned.