Complex Care Manager(8)Care Mgmt & Coordination(FT Day)
MemorialCare Medical Foundation
October 12, 2018
Fountain Valley, California
Full Time - Experienced
Supports Case Management (CM) activities and programs both at Shared Services and in Provider clinics based on patients with MCMF’s Managed Care and ACO populations.
Identifies and evaluates members for enrollment into one of the Memorial Care Medical Foundation Case Management programs (SPARK/IOCP, Complex, Care Coordination) through physician referral, utilization data, inpatient referral, predictive modeling software, health plan referral, patient and family referral, and other sources as they occur.
Carries caseload mix as set by department manager to align with overall equity, acuity and organization goals.
Assesses, plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing and supporting the member’s health status and goals.
Adheres to CM Standards of Practice and uses evidence-based clinical treatment guidelines, preventive guidelines, protocols, and other metrics in the development of Care Plans and Shared Action Plans.
Monitors outcomes of the plan that are adherent to all regulatory requirements and are patient-centered, promoting efficiency and quality in the delivery of healthcare for the designated patient population. Modifies the care plan based on patient needs/stated goals and per department’s productivity standards and quality measures.
Works effectively with other members of the health care team and acts as liaison to optimize interventions.
Coordinates services with appropriate physicians, facilities, contracted providers, and ancillary providers (disease management, behavioral health, social services and community resources) as indicated.
Dedicated to the delivery of high-quality patient care and service, has a continuous learning approach to work, and finds opportunity in challenges and barriers.
Maintains comprehensive and confidential patient records in compliance with all HIPAA regulations and per documentation standards with the patient’s electronic medical record or other approved documentation system.
Attends and participates in appropriate Patient Care Conferences, committees or related meetings, providing comprehensive and accurate case management reports and documents as required.
Supports the organization’s goals and mission statement and in a professional manner.
Maintains and complies with all MCMF policy and procedures.
Performs additional duties/tasks as assigned by the Supervisor and/or Manager.
Experience List the minimum experience, skills, knowledge and abilities required to do the job. Required:
Work experience in Microsoft Word, Microsoft Excel and Microsoft Outlook.
Work experience applying evidence-based criteria (i.e.: MCG, lnterqual); Health plan medical policy / clinical coverage guidelines.
Clinical Nursing Experience in a hospital or like setting (2 years min)
Previous Case Management experience
Previous and or ability to learn use of electronic medical record, UM/CM platforms or electronic health record preferred.
Knowledge of CMS (Centers for Medicare and Medicaid Services) coverage policies required.
Education List the education licensures or certifications preferred or required to do the job. Required:
Current California Registered Nurse license (RN), Licensed Vocational Nurse (LVN) or MSW/LCSW
Associate's degree (AA) in nursing or equivalent from a two-year college or technical school.
Bachelor of Science in Nursing, Social Worker or equivalent.
Internal Number: MEM002554
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