This position works under the direct supervision of the Manager, Case and Disease Management and is responsible for the operational delivery of the plan’s case management and care coordination programs and processes.  

The Complex Case Manager  Nurse will provide case management services for health plan members with highly complex medical and psychiatric conditions where advocacy and coordination are required to help the member reach the optimum functional level and autonomy.   The Complex Case Manager Nurse will be working closely with a team comprised of the Complex Case Manager Nurse, a Medical Social Worker and a Health Navigator. This position may be eligible to work remotely 1-3 days per week under the direct supervision of the Manager, Case and Disease Management following completion of working full time on site for 3 months.  This collaborate team approach to case management will include key departments at the health plan, inlcuding Utilizaiton Management and Pharmacy, which may provide clincal expertise and data on patient utilization patterns, often in real time, to the program. Externally, the team will work closely with community partners to make referrals for care and resources and to best manage members across the care spctrum and among multiple health care systems. The goal of the Complex Case Managemt program is to improve members’ quality of life and assure cost-effective outcomes by utilizing all available and appropriate resources.  

Principal responsibilities include: • Perform the primary functions of assessment, planning, facilitation and advocacy through collaboration with the member and other health care resources involved in the member’s care. • Work closely with licensed and unlicensed staff to co-manage the care of complex cases telephonically through regular contact with members, caretakers, healthcare professionals and others involved in the member’s care • Carry a caseload of members indicidually and co-managed as a team • The nurse will act a subject matter expert on the nusing process and perspective for the team • The nurse will be resposnible for triage and all aspects of the nursing process, including assessing, diagnosing, planning, implementing, and evaluating care.  • Develop multi-disciplinary care plans with the input of the member and PCP  to address identified member problems using evidence-based goals and interventions

• Participate in the ongoing process of a identifying the health plan’s members who are most at-risk of poor health outcomes and in need of care management services. • Participate in weekly Multidisciplinary Care Team Meetings and be able to present comple medical cases before the deparmtent wide team • Work collaboratively with health plan’s providers, particularly member’s primary care providers and specialist, in order to provide highly cooridinated and often specialized care • Assess member medical and social determinants of health and

• Communicate with providers, members, and community resources as necessary, to support the planning, implementation and evaluation of care management programs. • Employ a patient advocacy approach with a seamless integration of services is required and must be balanced within the member's benefit structure. • Complete other duties and special projects as assigned.  

ESSENTIAL FUNCTIONS OF THE JOB • Communicate and coordinate required services for members with PCP’s and specialists. • Manage, document, and maintain casework in accordance with NCQA accreditation guidelines and state regulators. • Build and maintain effective relationship with designated members and those members’ families or caregivers. • Maintain case management records. • Develop appropriate member care plans and appropriate member assessments. • Serve as a clinical resource to staff, as needed. • Perform writing, administration, analysis, and report preparation. • Research and develop working relationships with appropriate community resources to service members. • Provide direction to ancillary team/pod staff members who will provide additional coordination activities for health plan members being case managed. • Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.  

PHYSICAL REQUIREMENTS • Constant and close visual work at desk or computer. • Constant sitting and working at desk. • Constant data entry using keyboard and/or mouse. • Frequent use of telephone headset. • Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. • Frequent lifting of folders and other objects weighing between 0 and 30 lbs. • Frequent walking and standing.  

MINIMUM QUALIFICATIONS: EDUCATION OR TRAINING EQUIVALENT TO:

• BSN or MSN required. • Registered Nurse license, active and unrestricted licensed in the State of California before start of work. • Current CPR and first aid card prior to or within six months of hire is preferred. • Certification in case management (CCM etc.) preferred or willing to become certified within 12 months of hire or a date agreed to by supervisor.   

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Three years experience in clinical case management  required • Three years of clinical experience in an acute care setting desired • Masters in Case Management will be considered in lieu of the above listed required clinical CM and desired acute experience

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Excellent verbal and written communications skills. • Knowledge of Medi-Cal and Medicare regulations a plus. • Ability to motivate. • Knowledge of and experience with community and other resources  a plus • Ability to prioritize case load. • Experience in use of Windows including Microsoft Office suite. • Experience in use of Care Management Software applications a plus.

Pay Range: $77,710 - $116,570/annually