Case Manager - Capitated Business

Value Based Care R.N. for Capitated Programs

The Value Based Care R.N. for Capitated Programs is responsible for coordinating and managing patient care within capitated and risk-based contract environments. This role focuses on ensuring quality, cost-effective, and clinically appropriate care for members by partnering with our MSO partners to conduct assessments, develop care plans, coordinate services, and collaborate with providers across the continuum of care. The Value Based Care R.N. ensures compliance with clinical guidelines, regulatory requirements, and delegated risk arrangements while driving optimal outcomes for members and contracted partners.

Key Responsibilities

Care Coordination & Case Management

• Work with MSO partners and physicians to conduct comprehensive clinical assessments for members in capitated programs to ensure appropriate level of care, length of stay management and repatriation of member who are out of network.
• Assist MSO Partners with coordinating services including specialist referrals, home health, DME, social services, and community resources.
• Monitor member progress and update care plans as needed.
• Prevent avoidable ER visits, hospitalizations, and readmissions.

Utilization & Cost Management

• Evaluate medical necessity using clinical criteria such as InterQual or MCG.
• Support utilization optimization within capitated and risk-bearing arrangements.
• Collaborate with Contracted IPA's /MSOs to manage high-risk cases and ensure appropriate site-of-care decisions.
• Monitor utilization trends and identify opportunities for improvement.

Provider & Member Collaboration

• Serve as a liaison between Hospital and, MSO's, physicians, and ancillary providers.
• Ensure coordinated and effective care delivery across all stakeholders.
• Partner with MSO's, Providers and care teams to support delegated or capitated workflows.

Compliance & Documentation

• Document all activities accurately in care management systems.
• Maintain compliance with Medicare, Medicaid, commercial regulations, and NCQA standards.
• Adhere to delegated risk agreements and reporting requirements.
• Participate in audits, quality reviews, and process improvement initiatives.

JOB QUALIFICATIONS

Minimum Education (Indicate minimum education or degree required.)

Graduate of an accredited RN Program

Preferred Education (Indicate preferred education or degree required.)

Completion of Case Management Course Preferred

Minimum Work Experience and Qualifications (Indicate minimum years of job experience, skills or abilities required for the job.)

Ability to communicate effectively verbally and in writing. Must be able to work in a union environment. Minimum two years' experience as a RN in an acute care setting. Ability to communicate effectively verbally and in writing.

Preferred Work Experience and Qualifications (Indicate preferred years of job experience, skills or abilities required for the job.)

Minimum two years as a Case Manager Preferred.

Required Licensure, Certification, Registration or Designation (List any licensure or certification required and specify name of agency.)

Current California RN license American Heart Association BLS Card Current Los Angeles County Fire Card required (within 30 days of employment) Assault Response Competency (ARC) required (within 30 days of hire)

Full-Time, 80 hrs/week, Non-Exempt, On-site