Job Summary
Provides case management services to a caseload of low- and medium-risk patients. Interviews patients and their caregivers to evaluate needs, goals, and current services. Determines initial eligibility, benefits, and education for all admissions, assessing medical necessity and required level of care to inform physicians. Reviews and enters authorization data. Develops a client-focused case management plan in collaboration with healthcare team, patient, and caregivers that is consistent with regulatory, accreditation, and regional guidelines. Assists patients with gaining access to care based on their needs, making referrals as appropriate. Coordinates resources and services to assure continuity and quality of care. Attends case management rounds with clinician and reviews authorizations and diagnoses as needed. Assesses patient progress toward treatment milestones and care plan goals. Identifies barriers to achieving goals and ensures that they are discussed with the patient and care team thoroughly. Verifies that all services remain consistent with established guidelines and standards. Documents the patient’s case in all medical files. Reviews benefits/services available to patients, caregivers, and other members of the community and assists with problem solving identified concerns. Identifies patients ready for disposition planning activities. Develops and communicates a comprehensive disposition plan in collaboration with the patient, caregivers, physician, nurses, social services, and other healthcare providers and agencies. Obtains authorizations as needed for patient services. Attends professional seminars, workshops, and approved educational programs and workshops. Monitors operational team data and key metrics applied to own work. Makes suggestions for change or improvement as needed. Ensures adherence to policies to meet regulatory requirements.
Essential Responsibilities
Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome.
Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team.
Drives services related to the initial case assessment by interviewing patients and their families to evaluate needs, goals, and current services with minimal day-to-day supervision; determining initial eligibility, benefits, and education for all admissions independently; reviewing and entering authorization data and identifying and documenting inaccuracies; recommending research plans that identify new and/or existing options to assure that quality, cost‑efficient care is provided; and leveraging comprehensive knowledge to assess medical necessity for hospital admission and required level of care to inform physician.
Provides services related to monitoring and evaluating plan of care by coordinating resources and services to assure continuity and quality of care, and sharing professional knowledge with team members. Reviews and updates authorizations, attends case‑management rounds with clinicians, and reviews diagnoses as needed. Contacts patients periodically to assess progress toward treatment milestones and care plan goals independently. Identifies barriers to achieving goals and ensures that they are discussed with the patient and care team thoroughly independently. Verifies that all services remain consistent with established guidelines and standards independently. Documents and updates the patient’s case in all medical files independently.
Drives services related to the case‑planning process by creating a client‑focused case management plan with treatment goals based on the patients and families/caregivers needs under limited direction; collaborating with health‑care team, patient, and caregivers to assure plan of care is safe, agreeable, and appropriate with minimal guidance; and validating that the plan is consistent with regulatory, accreditation, and regional guidelines independently.
Supports efforts to remain updated on current research, policies, and procedures by attending seminars, workshops, and approved educational programs and workshops specific to professional needs; contributing to the implementation of systems, processes, and methods to maintain team knowledge of community resources; monitoring operational team data and key metrics applied to own work independently; making suggestions for change or improvement as needed independently; and ensuring adherence to policies to meet regulatory requirements.
Provides services related to patient disposition by identifying patients ready for disposition planning activities under limited guidance; developing, evaluating, coordinating, and communicating a comprehensive disposition plan in collaboration with the patient, family, physician, nurses, social services, and other healthcare providers and agencies to meet each patient’s personal, psychosocial, economic, and cultural needs with guidance; and obtaining authorizations/approvals as needed for services for the patient with minimal supervision.
Connects patients with existing services by assisting patients with gaining access to care based on their needs and integrating or referring them into existing programs/services independently; referring patients to outside entities, ambulatory case managers, care managers, social workers, and/or internal/external resources as appropriate with minimal guidance; and aiding in making location‑specific adaptations as necessary.
Serves as liaison between internal and external care by reviewing benefits/services available based on regulations or specific coverage to patients, families, and other members of the community and assisting with problem solving identified concerns under limited supervision; providing case management to a caseload of low- and medium‑risk patients referred to external facilities/agencies with minimal supervision; applying standard strategies and concepts to propose recommendations in interdisciplinary team meetings with internal and/or external stakeholders; and leveraging comprehensive knowledge of the patient’s case to act as a resource for physicians, health plan administrators, and contracted vendors.
Minimum Qualifications
Bachelor’s degree in Nursing or related field AND minimum three (3) years of experience in nursing, case management, or a directly related field.
Registered Nurse License (California) required at hire.
Additional Requirements
Knowledge, Skills, and Abilities (KSAs): Written Communication; Confidentiality; Health Care Compliance; Maintain Files and Records; Acts with Compassion; Business Relationship Management; Company Representation; Managing Diverse Relationships; Relationship Building; Member Service; Patient Safety; Quality Assurance and Effectiveness; Community Health.