Clinical Services Nurse

To provide support and facilitate care of members who require case management. To work collaboratively with Health Plan and Hospital Case Management Departments in the facilitation of services. To collaborate with the treating physician and IPA Medical Director in the review and decision-making process regarding the facilitation of appropriate health care and service requests. Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes. If applicable, the CM will coordinate care for Cal Medi-Connect program members to ensure all aspects of the CMC program description are implemented and followed. A case manager is a licensed LVN. A care manager can be a licensed social worker (MSW) or licensed nurse (LVN). NEW GRADS WELCOME! All candidates for any case management position will have the appropriate education and experience to meet requirements and the service needs of the populations. Principal Duties and Responsibilities (* = essential functions): To utilize the Case Management functions: assessor, planner, facilitator, advocate. To facilitate services at the appropriate Health Plan center of excellence. To review and process clinical information in accordance with regulatory mandates to facilitate patient healthcare and services across the continuum of care. To interface professionally and courteously with all internal staff and external customers to ensure appropriate exchange of information. To prepare and participate in health plan audits onsite as required. To actively participate in Utilization Management Committees in regard to Case Presentations and problem‑solving. To participate in the development of Case Management Policies and Procedures. To actively participate in the discharge planning process. To monitor and participate in the SNP/Duals program. To ensure all members are living in the least restrictive environment. To follow the UM/QI/CM/SNP/CMC program descriptions. To perform other duties as assigned. Job Specifications (KSAs): Requires extensive and specialized knowledge of utilization and case management processes, as is generally acquired by 1 year or greater of experience as a case manager in a Managed Care Environment, and successful completion of a nursing program. Requires prior Case Management experience, preferably with catastrophic cases. Requires an active LVN license in the state of California. Requires excellent written and verbal communication skills. Requires computer experience, particularly Microsoft Word, Excel, familiarity with Cozeva or EZCap, a plus, and the ability to learn new software applications quickly. Requires problem‑solving and critical thinking skills. Requires professional demeanor and the ability to contribute to a positive work environment. Requires extensive knowledge of health plan guidelines. Position Performance Criteria: Demonstrates proficiency in UM and Case Management, including but not limited to: Referral review Concurrent/inpatient review and bed-day management. Demonstrates the effective practice of Case Management Standards of Care, including: Assessment Case Identification and Selection Planning Monitoring Evaluating Outcomes Sets appropriate priorities to meet departmental goals and objectives, including but not limited to: Demonstrates ability to efficiently manage case load. Demonstrates ability to set appropriate priorities. Consistently renders prudent and sound decisions. Manages multiple tasks while meeting required timeframes. Adheres to departmental policies and procedures. Demonstrates knowledge of Health Plan guidelines. Consistently demonstrates professional work ethic, collegial interaction with others, and reliability, while contributing to a positive work environment, including but not limited to: Professional appearance and demeanor. Meets departmental attendance needs on‑site. Participates verbally in group activities, i.e., staff meetings, etc. Demonstrates respect for co‑workers and customers. Works collaboratively with other departments to identify and resolve issues. #J-18808-Ljbffr Physicians Data Trust