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Case Manager
Ref No.: 18-41412
Location: Rancho cardova, California
Position Type:Contract
Start Date: 06/14/2018
Role: Case Manager
Location : Rancho cardova, CA
              
Job Description: Federal Employee Program Care Managers perform integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members' care including clinical nurses and treating physicians. Care Managers determine, develop and implement a plan of care based on accurate and comprehensive assessment of the member's needs. Care Managers apply detailed knowledge of Cross of California (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.
 
Qualifications:
  • Bachelor' s of Science in Nursing or advanced degree preferred.
  • Active California RN license required.
  • Must have specialty training in one of the following specialized areas: case management, disease management, home health/hospice, cardiac rehab or respiratory therapy with children or adults.
  • Seven years' experience in case management, utilization management, post service review, quality management or health plan/IPA management.
  • Case Management, Quality or other equivalent certification that is related to the specific area to be managed is required.
  • Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources.
  • Strong supervisory, communication and negotiation skills.
  • Able to operate PC-based software programs including proficiency in Word and Excel.
 
Responsibilities:
  • Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs.
  • Applies detailed knowledge of FEP PPO and Cross of California's (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.
  • Works with complex cases, promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits.
  • Provides guidance to the provider network.
  • Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care.
  • Coordinates Care for Lower Level of Care coordination such as Skilled Nursing Facility, Home Health, Home Infusion, Rehab
  • Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease).
  • Makes referrals to Quality Management, Catastrophic Case Management and Appeals and Grievance Department.
 
Additional Skills:
  • Able to operate PC-based software programs including proficiency in Word and Excel.
  • Strong clinical documentation skills, independent problem identification and resolution skills.
  • Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills.
  • Competent understanding of NCQA and federal regulatory requirements.
  • Knowledge of Coordination of Care, prior authorization, level of care and length of stay criteria sets desirable.
  • Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care.
  • Solid case preparation
  • Demonstrated leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making.