RN, Clinical Care Manager I

Gold Coast Health Plan•Camarillo, CA

50d•Hybrid

About The Position

The Gold Coast Health Plan (GCHP) RN, Clinical Care Manager I supports the GCHP mission to improve the health of the members through provision of the best possible quality care and services. As defined by the Case Management Society of America (CMSA): Care management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes. The RN, Clinical Care Manager I works closely with other team members and is a role model and resource to colleagues. This position acts as a bridge by facilitating communication between the member, member’s family and the providers. The RN, Clinical Care Manager I also provides member advocacy and education to maintain or improve clinical outcomes.

Requirements

Bachelor's Degree (four-year college or technical school) is preferred, Field of Study: in a health-related field and managed care experience is desired
Registered Nurse (RN) valid and current license.
2 plus years of experience in the health care field. Required.
Care management, discharge planning, or equivalent combination of education and experience.
Ability to evaluate clinical and other health data and to communicate effectively both orally and in writing.
Ability to synthesize thoughts and plans succinctly in writing.
Ability to balance multiple tasks.
Strong organizational skills.
Critical thinking skills.
Flexibility in role delineation and workload assignments.
Team player

Nice To Haves

Managed care experience in a health plan, preferred.
Strong background and knowledge of computer skills in MS Office products.
Active, valid and unrestricted license, California Registered Nurse CCM or other CM certification preferred.
A valid and current Driver's License, Auto Insurance, and professional licensure(s)
Bilingual in English and Spanish preferred
An attitude to excel, a special empathy for working with multiple populations, an investigative personality and a willingness to mentor colleagues.
A working knowledge of Medi-Cal and related policy and regulations.

Responsibilities

Assess and identify members who may benefit from additional education, clinical support, and connecting them with appropriate medical providers.
Promote the most cost-effective healthcare delivery by coordinating with the medical management team.
Engage members into care coordination activities to reduce care gaps.
Evaluate for and work toward elimination of barriers to care.
Formulation of a member-centric care plan in partnership with the member.
Collaborate with internal partners including but not limited to; social workers, health education, pharmacy staff and ECM/ Community Supports team, member services
Ensure confidentiality of utilization review, quality assurance information, and individual beneficiary identification
Assist with data collection for special member determination as required
Prepare written reports such as summaries of case management functions and updates of case status, use of covered services, supporting and reporting required metrics and other pertinent performance data, as directed
Provide accurate documentation to meet departmental policies, regulatory requirements and audits
Attend community meetings concerning health issues or provision of health-related services Establish and maintain effective working relationships with community resources and service agencies
Strong organizational, delegation and task prioritization skills
Member advocacy focus
Knowledge of required regulatory timelines to ensure department compliance with State contracts
Ability to convey empathy and is nonjudgmental of the member
Demonstrates team support by consistently seeking opportunities to recognize and promote colleagues
Ability to stay calm and professional when working with internal and external partners
Exhibits accountability by maintaining good attendance
Adhere to all GCHP Policies and Procedures and meet required performance standards
Review referral requests for Enhanced Care Management and Community Supports referral requests.
Authorize referral requests for various ECM and CS providers.
Serve as liaison for Justice Involved population.
Attend National Health Foundation meetings with Enhanced Care Management.
Attend CalAim meetings with Ventura County.
Educate members, staff and providers about policies for ECM and CS.