Case Management Assistant, TCS (PHM)- Bakersfield 1.1

Case Management Assistant (CMA) - Transitional Care Services

The Case Management Assistant (CMA)- Transitional Care Services provides support to the Population Health Management (PHM) team with a focus on members undergoing transitions of care. The CMA assists in enhanced care coordination activities for members transitioning between settings such as emergency departments, inpatient admissions, and post-acute facilities. This role supports members across the PHM continuum, from low risk to highly complex, by coordinating services, scheduling timely follow-up appointments, gathering clinical information, and conducting outreach to confirm that needs are being met. The CMA plays a proactive role in contacting members during transitions, including prior to discharge, to help coordinate the transition process and post-discharge follow-up. The goal is to reduce readmissions and avoidable ER visits by supporting effective transitional care services. The role may also require assignment at a designated clinic site, with responsibilities carried out through telephonic, virtual, and in-person engagement in collaboration with members, providers, and care teams.

Job Duties and Responsibilities:

• Work collaboratively with the PHM team, including nurse case managers, social workers, and TOC clinic staff, to support members in need of transitional care services.
• Contact members during care transitions, especially prior to discharge, to help coordinate the transition process and post-discharge follow-up, with the goal of reducing readmissions and avoidable ER visits.
• Gather clinical information and assist with coordinating post-discharge services, including home health care, prescriptions, durable medical equipment (DME), and transportation, ensuring referrals are received and confirming members understand follow-up needs.
• Schedule primary care provider (PCP) post-discharge visits and/or Transitions of Care (TOC) Clinic appointments in a timely manner.
• Proactively coordinate with referral sources and internal partners to support seamless member transitions between care settings.
• Support PHM members of all risk levels, from low to complex, who are experiencing transitions of care (e.g., ED, inpatient, post-acute, and other settings).
• Contact members at regular intervals per care plan needs and acuity level, or as directed by the member's Primary Case Manager.
• Initiate and/or complete applicable assessments, such as Health Risk Assessments (HRA), initial assessments, and/or Transitional Care Services (TCS) assessments, and consistently document activities and encounters in the case management system.
• Support case managers with follow-up, communication with agencies, and preparation/distribution of documents or reports.
• Report and escalate member concerns, variances, or changes in condition to the appropriate care team members, including Nurse Case Managers and Social Services staff, to ensure timely intervention and coordinated follow-up.
• Assist members with appointment scheduling, transportation, referral coordination, and other care coordination needs.
• Gather clinical information from outside sources such as SNFs, PCPs, specialists, hospitals, and applicable electronic health record systems, and upload them in the case management (CM) system.
• Ensure relevant TOC Clinic records are shared with the member's PCP to help facilitate continuity of care.
• Verify member eligibility, demographics, benefits, and case management program eligibility.
• Ensure closed-loop referrals to community supports, housing, and social service agencies, with follow-up to confirm services were delivered, including services authorized by the organization.
• Participate in Interdisciplinary Care Team (ICT) meetings by gathering and presenting information and communicating member needs and preferences.
• Serve as an associate and resource to members, providers, staff, and external customers regarding policies, benefits, and care coordination.
• Provide administrative support, including answering phones, assisting with correspondence, and maintaining data systems.
• Conduct outreach to members to verify needs are being met and services delivered.
• May be assigned to conduct in-person meetings with members during clinic visits.
• Attend mandatory staff and departmental meetings.
• Assist with training and orientation of new staff, as requested.
• Perform other duties as assigned.

Qualifications:

• High School diploma or GED required.
• Minimum of 3 years of experience in a healthcare, hospital, or community health setting.
• Experience in a managed care environment preferred (IPA, HMO, or health plan)
• Familiarity with transitional care, care coordination, or case management support preferred.
• Medical Assistant or Community Health Worker certification preferred

Skills and Abilities:

• Ability to respect the needs of members, caregivers, team members, and others while providing excellent customer service.
• Ability to work effectively as part of a team, collaborating with interdisciplinary staff to achieve shared goals.
• Sensitivity to members' social, cultural, language, physical, and financial differences.
• Strong critical thinking and problem-solving skills, with ability to identify issues and propose solutions.
• Ability to prioritize tasks and adapt to changing member situations and needs.
• Strong organizational skills; able to work independently while managing multiple tasks.
• Excellent verbal and written communication skills.
• Proficiency with case management systems, Microsoft Office (Word, Excel, PowerPoint), and internet-based tools.
• High attention to detail with accuracy, thoroughness, and persistence in follow-up.
• Ability to collaborate effectively with an interdisciplinary team.
• Commitment to professionalism, continuous learning, and quality improvement.
• Ability to always maintain confidentiality.