RN Case Manager

RN Case Manager

The RN Case Manager is responsible for providing on-going case management services for Santa Clara Family Health Plan (SCFHP) members. As a SCFHP member advocate, the RN Case Manager facilitates communication and coordination among all participants of the care team to ensure member identified goals and needed services are provided to promote quality cost-effective outcomes. Through the development and implementation of member individualized care plans, the RN Case Manager provides medical and psychosocial case management support to help coordinate resources and services for individuals across the healthcare and social services continuum, and facilitate the use of available healthcare benefits in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

1. Conduct, review and document comprehensive clinical and/or psychosocial assessments and on-going follow-up interventions to measure progress towards meeting goals as they relate to a member's physical, psychosocial, environmental, safety, developmental, cultural and linguistic needs.
2. Maintain case files by assuring that they are documented in accordance with SCFHP policies and procedures, state and federal requirements and organized in a manner that adheres to standards for audit requirements.
3. Facilitate involvement of the member and/or family/responsible party for development and implementation of a member specific care plan which includes individualized prioritized goals.
4. Coordinate member's care with PCP, Specialists, Behavioral Health and Long Term Services and Supports providers to assist member to achieve or maintain a level of functional independence which allows them to remain at home or in the community.
5. Facilitate and coordinate communication with member's interdisciplinary care team including SCFHP internal staff, as well as the member's physicians, specialists, public services, community agencies and vendors to ensure care plan development and coordination of benefits and services.
6. Facilitate successful transition of care for members who move between care settings by coordinating services for medical appointments, pharmacy assistance and by facilitating utilization review.
7. If assigned to MLTSS, support the transition of long-term care members residing in nursing facilities to a lower level of care, or community setting in partnership with MLTSS providers and programs.
8. If assigned to Community Based Adult Services (CBAS):
   • Conduct face-to-face, on-site eligibility determinations for CBAS services with members using the standardized California Department of Health Services approved tool CBAS Eligibility Determination Tool (CEDT) & Patient Health Record Quick Guide;
   • Review and approve Individual Plan of Care for CBAS members; and
   • Provide care coordination to targeted CBAS members including assessment, care plan implementation and care transitions.
9. Conduct telephonic and/or visits/assessments, as needed in the home, facility or community setting.
10. Collaborate with team members on cross-departmental improvement efforts, quality improvement projects, optimization of utilization management, and improvement of member satisfaction.
11. Attend and actively participate in Health Services meetings, operational meetings, training and coaching sessions, including off-site meetings as needed.
12. Perform other duties as required or assigned.

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. Active California RN License without restriction.
2. Minimum three years of experience in case management, discharge planning, or education or certifications, or equivalent experience.
3. Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management.
4. Clinical knowledge and critical thinking skills with the ability to assess individualized whole-person care needs necessary to develop an effective care plan.
5. Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance.
6. Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills.
7. Experience working with designated member population (e.g. behavioral health, seniors and persons with disabilities, children).
8. Ability to work within an interdisciplinary team structure.
9. Ability to conduct home, facility and other community-based visits.
10. Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events.
11. Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the operations as dictated by business needs.
12. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs.
13. Ability to use a keyboard with moderate speed and a high level of accuracy.
14. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing as mandated by nursing scope of practice.
15. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes.
16. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position.
17. Ability to maintain confidentiality.
18. Ability to comply with all SCFHP policies and procedures.
19. Ability to perform the job safely and with respect to others, to property and to individual safety.

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time.
2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds.
3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less.
4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment.
5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone.
6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail.

General office conditions. May be exposed to moderate noise levels.

Santa Clara Family Health Plan