Department(s): Case Management
Reports to: Manager, Case Management
FLSA status: Non-Exempt
Salary Grade: L - $77,000 - $127,094
About CalOptima Health
CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County’s best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay!
About the Position
Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for CalOptima Health’s members. The Medical Case Manager will facilitate communication and coordination among all participants of the health care team and the member to ensure the services provided promote quality and cost-effective outcomes. The incumbent will be responsible for providing intensive case management, which includes assessment, planning, implementation, coordination, monitoring and evaluation of the member’s needs.
Duties and Responsibilities:
Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.
Performs comprehensive, disease specific, clinical assessments of all identified cases which includes, but is not limited to, assessment of: Member’s physical, functional, social and psychological status
Member’s cultural and linguistic needs
Caregiver resources and available benefits
Develops and implements a member’s specific care plan which includes prioritized goals.
Schedules follow-ups to assess progress towards goals and identifies barriers to meeting goals.
Communicates with member’s physicians, specialists, community agencies and vendors to ensure coordination of services.
Follows CalOptima Health’s protocol for documenting all case interventions.
Facilitates Interdisciplinary team meetings as applicable.
Collaborates with interdepartmental staff in case resolution as needed.
Identifies cases needing manager, director or medical director review or input, routes accordingly and closes cases according to procedures and guidelines in a timely manner.
Prepares and maintains appropriate documentation of patient care and progress within the care plan.
Advocates in the member’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
Completes other projects and duties as assigned.
Experience & Education: .
Associate’s degree in Nursing (ADN) or related field required.
Current unrestricted Registered Nurse (RN) license to practice in the state of California required.
5 years of clinical experience and/or managed care experience required.
An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Preferred Qualifications:
Bachelor of Science in Nursing (BSN) degree or related field.
Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).
Physical Demands and Work Environment:
The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical demands: Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must be able to talk and hear, particularly for regular communication on the phone. Employee may at times be required to deal with significant time pressures if required to work on projects that have timeframes attached.
Work Environment: Employee will have one-on-one contact with other employees in a quiet environment where hearing and listening is paramount. Employee is expected to use diplomacy and problem-solving skills to procure data and information from other sources, as well as handle incoming public inquiries. Office environment with controlled office temperatures.
About our Benefits & Wellness options:
At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.
CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability enings or apply for a job on this site as a result of your disability.
About the company CalOptima is a county organized health system that administers health insurance programs for low-income children, adults, seniors and people with disabilities in Orange County.