Enhanced Care Management Clinical Specialist II

L.A. Care Health Plan•Los Angeles, CA

About The Position

The Enhanced Care Management (ECM) Clinical Specialist II is responsible for the management and oversight activities associated with L.A. Care's ECM network. The position reports to the Supervisor of ECM and receives clinical supervision as needed from the Medical Director of Care Management. The position is responsible for providing oversight, feedback, and technical assistance to ECM Providers to support effective delivery of ECM services and ensure compliance with local, State, and Federal regulations, statues and guidelines. The position is responsible for conducting regular meetings with providers, reviewing Assessments & Care Plans, providing guidance on clinical best practices, and assisting with escalation of cases that require additional assistance from L.A. Care. The position works directly with Care Management and Provider Network Management staff to inform Provider capacity-building and training activities related to the ECM Program operations.

Requirements

Minimum 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments.
Previous care management experience to include auditing/oversight/performance management experience.
Current knowledge of clinical standards of care and disease processes, and community resources.
Excellent verbal and written communicating skills; excellent interpersonal skills.
Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine the most effective member-centered interventions.
Proficiency in Microsoft Office MS Office applications.
Maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.
Ability to solve complex issues and identify creative solutions with external agencies.
Excellent project management skills.
Working knowledge of Medi-Cal and Medicare regulations.
Licensed Clinical Social Worker (LCSW); Current and unrestricted California License or Registered Nurse (RN); current and unrestrited California License.

Nice To Haves

Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese
Certified Professional in Utilization Review (CPUR)
Certified Case Manager (CCM)
Certification in Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), Utilization Management or Compliance

Responsibilities

Conduct regular monitoring and coaching with Providers to review aggregate progress and individual ECM member cases. May use telephonic, onsite, or written methods and both group and individual Provider activities to monitor performance related to Provider clinical and service requirements.
Provide guidance on best practices to ECM providers.
Conduct a monthly random sample review of Assessments and Care Plans created by the ECM Provider.
Identify any gaps in the Care Plan services or regulatory compliance and provide coaching and feedback to the Provider to improve.
Identify any issues that require escalation or more frequent monitoring of the ECM Provider.
Organize and perform file review process in accordance with given criteria to include collection & verification of supporting documentation, recording received information in appropriate tracking systems, and communicating end results of requests in writing and/or verbally.
Provide training, education and consultation as necessary to Providers.
Collaborate with other ECM staff on identifying topics and developing materials for Provider training and capacity building.
Assist ECM Providers with escalation of ECM member cases that require additional assistance from L.A. Care.
Assist ECM Providers with the coordination of member care with internal L.A. Care departments such as Care Management (CM), Utilization Management (UM), Managed Long Term Services and Support (MLTSS), Social Services, Behavioral Health, Community Health, Health Education, as well as external providers such as Participating Physician Groups (PPGs) and Primary Care Physicians (PCPs).
Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of ECM.
Assist co-workers with special projects or work volume as required.
Communicates any barriers to supervisors in an efficient and effective manner.
Perform other duties as assigned.