Enhanced Care Management, Nurse ( Bilingual Preferred) / Job Req 704962819

PRINCIPAL RESPONSIBILITIES:

This position works under the direct supervision of the Clinical Manager, Enhanced Care Management (ECM) and is responsible for the operational delivery of the plan's ECM case management and care coordination programs and processes.

The Enhanced Care Management Nurse will provide oversite of ECM case management services for health plan members with highly complex medical and psychiatric conditions where advocacy and coordination are required to help the member reach the optimum functional level and autonomy. The ECM Nurse will be working closely with a team comprised of the Health Navigators and external ECM Providers in the community. This collaborate team approach to case management will include key departments at the health plan, inlcuding Utilization Management and Pharmacy, which may provide clinical expertise and data on patient utilization patterns, often in real time, to the program. Externally, the team will work closely with community partners to make referrals for care and resources and to best manage members across the care spectrum and among multiple health care systems. The goal of the ECM program is to improve members' quality of life and assure cost-effective outcomes by utilizing all available and appropriate resources.

Principal responsibilities include:

• Perform the oversite functions of ECM member assessments, planning, facilitation and advocacy through collaboration with the ECM Providers and other health care resources involved in the member's care.

• Work closely with licensed and unlicensed staff to co-manage the care of complex cases telephonically through regular contact with members, caretakers, healthcare professionals and others involved in the member's care

• The nurse will act a subject matter expert on the nursing process and perspective for the team.

• The nurse will be responsible for triage and all aspects of the nursing process, including assessing, diagnosing, planning, implementing, and evaluating care.

• Review and audit multi-disciplinary care ECM plans with the input of the member and PCP to address identified member problems using evidence-based goals and interventions per DHCS guidelines.

• Participate in the ongoing process of a identifying the health plan's members who are most at-risk of poor health outcomes and in need of care management services.

• Participate in recurring multidisciplinary care team meetings with our ECM Providers and be able to present guidance and support as a representative of the Managed Care Plan team.

• The nurse will work with ECM members enrolled in Enhanced Care Management per Department of Health Care Services guidelines.

• Work collaboratively with the health plan's providers, particularly members' primary care providers and specialists, in order to provide highly coordinated and often specialized care.

• Assess member medical and social determinants of health; including housing status and other Community Supports, as part of care plans reviews and multidisciplinary care team meetings.

• Serve as primary clinical reviewer for Utilization Management reviews for ECM services.

• Collaborate in a positive interdisciplinary approach with other Case Managers and CM/DM staff, Medical Services, Provider Services, Member Services departments as well as community resources to ensure the most appropriate level of care and optimal outcomes.

• Communicate with providers, members, and community resources as necessary, to support the planning, implementation and evaluation of care management programs.

• Employ a patient advocacy approach with a seamless integration of services is required and must be balanced within the member's benefit structure.

• Demonstrate a comprehensive understanding of coverage and benefits to promote appropriate service utilization and increase participant, member, and patient knowledge and satisfaction.

• Recognize and resolve continuity of care issues or other problem areas promptly.

• Educate and answer inquiries from participants, patients, and members and/or their family members about benefits, services, eligibility, and referrals with a positive and professional approach, promoting participant, patient, and member satisfaction and retention.

• Demonstrate a patient-centered approach to self-management skills for chronic disease conditions and provide decision support, urgent care support, symptom management support, basic health and wellness information, and educational resources.

• Identify and provide appropriate community referrals for participants, patients, and members, facilitating access to appropriate support services, including medical and social resources to address presenting issues and assist in the removal of barriers

• Assist with outreach, planning, and execution of regular Learning Collaboratives.

• If appropriate, work with state and federal eligibility and enrollment staff/vendors to assist in continuity in enrollment.

• Complete other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

• Communicate and coordinate required services for members with PCP's, ECM Provider, specialists, and community-based organizations.

• Manage, document, and maintain casework in accordance with NCQA accreditation guidelines and state regulators.

• Build and maintain effective relationship with designated ECM Providers and community-based organizations

• Maintain case management records.

• Review ECM member care plans and appropriate member assessments.

• Serve as a clinical resource to staff, as needed.

• Perform writing, administration, analysis, and report preparation.

• Research and develop working relationships with appropriate community resources to service members.

• Provide direction to ancillary team staff members who will provide additional coordination activities for health plan members being case managed.

• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or computer.

• Constant sitting and working at desk.

• Constant data entry using keyboard and/or mouse.

• Frequent use of telephone headset.

• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.

• Frequent lifting of folders and other objects weighing between 0 and 30 lbs.

• Frequent walking and standing.

Number of Employees Supervised: 0

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• Bachelor's degree required, BSN or MSN strongly preferred.

• Registered Nurse license, active and unrestricted licensed in the State of California required.

• Current CPR and first aid card prior to or within six months of hire is preferred.

• Certification in case management (CCM etc.) preferred or willing to become certified within 12 months of hire or a date agreed to by supervisor.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Three years experience in clinical case management strongly preferred.

• Three years of clinical experience in an acute care setting desired

• Masters in Case Management will be considered in lieu of the above listed required clinical CM and desired acute experience

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Excellent verbal and written communications skills.

• Fluency in English required.

• Fluency in Vietnamese, Cantonese, Spanish, Tagalog, or other appropriate language preferred.

• Knowledge of Medi-Cal and Medicare regulations a plus.

• Ability to motivate.

• Knowledge of and experience with community and other resources a plus

• Ability to prioritize case load.

• Experience in use of Windows including Microsoft Office suite.

• Experience in use of Care Management Software applications a plus.

SALARY RANGE $121,730.28 - $182,595.42 ANNUALLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.