Nurse Case Manager I

Overview:

To initiate and coordinate a multidisciplinary team approach to case management. Engages the
member/member’s representative in a care plan that assists the member in meeting his/her health
and wellness goals. Collaborates, assesses, plans, facilitates, evaluates, and advocates to meet the
comprehensive medical, behavioral, and psychosocial needs of the member, while promoting
quality and cost-effective outcomes. 

Responsibilities:

 

Essential Duties and Responsibilities

▪ Provides case management services independently for a caseload ranging in complexity
from basic to complex; acuity levels 1-4; performs field-based case management (acuity
level 5) with supervision.
▪ Initiates and coordinates individualized care plan for assigned members, addressing both
clinical and non-clinical components, and ensuring the care plan is available
to both the member and primary care provider.
▪ Resolves member needs by utilizing multidisciplinary team strategies, including Health
Services Integrated Rounds Meetings.
▪ Ensures a smooth implementation and continuum of care via effective and frequent
communication with providers, members, and identified health care designee.
▪ Elicits medical information from providers and reviews medical records, applying
clinical judgment to identify case management needs and support care coordination
activities. Facilitates medical records retrieval through appropriate channels and
established submission processes.
▪ Communicates clearly and effectively through all mediums of communication with
members, providers, vendors, community partners, and Partnership employees.
▪ Coordinates referrals and authorizations for services required to improve the
member’s health status.
▪ Maintains accurate and timely documentation, records, and case files in the Partnership
Case Management System for members in case management.
▪ Applies evidence-based interventions based upon member’s agreed upon goals/
▪ priorities
▪ Develops and maintains knowledge of a community based network of alternative
modes of care; aids member to connect with community-based organizations to support
and enhance wellness.
▪ Answers and triages department calls, and distributes department referrals with
guidance, in accordance with identified department service levels.
▪ Collaborates and coordinates with other internal departments to identify members
suitable for case management.

▪ Actively participates in essential skills training, unit and departmental assigned learning,
and other departmental activities as assigned.
▪ Functions collaboratively in a team environment, including acting as a support and
resource to other staff.
▪ Coordinates and participates in meetings with Partnership providers, as assigned.
▪ Collaborates with other departments with coordination of care needs through the course
of case management services.
▪ Demonstrates competence in NCQA documentation standards.
▪ Exhibits high professional standards as outlined in the CA Nurse Practice Act and
Partnership’s Code of Conduct.
▪ Performs other duties as assigned by the direct supervisor, including the assumption of
new duties.

 

Qualifications:

Education and Experience

 

Associate’s degree in Nursing required; Bachelor’s degree in Nursing
(or higher) preferred. 2 years of experience preferred, to include at least
one (1) year of case management experience and one (1) year in an
acute care setting; or equivalent combination of education and
experience. General knowledge of managed care and/or experience
with Medicaid population preferred.

 

Special Skills, Licenses and Certifications

Current and unrestricted California Registered Nurse License. Valid
California driver’s license and proof of current automobile insurance
compliant with Partnership policy are required to operate a vehicle and
travel for company business. Bilingual skills in an approved threshold
language is preferred.

 

Performance Based Competencies

 

 

Strong organizational, communication, critical thinking skills and
attention to detail required. Ability to work within an interdisciplinary
structure and function independently in a fast-paced environment while
managing multiple priorities and meeting deadlines. Effective
telephone and computer data entry skills required. Experience in
managed care business practices and ability to access data information
using various computer systems. Excellent English written and verbal
communication skills required.

 

 

 

Work Environment And Physical Demands

Able to utilize multiple computer platforms simultaneously. Daily use
of telephone and computer for most of the day. Standard cubicle
workstation. Must be able to lift, move, or carry objects of varying size,
weighing up to 10 lbs.

 

 

 

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

 

$51.28 - $66.67 

IMPORTANT DISCLAIMER NOTICE

 

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform.  The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change