1. Performs assessment of members’ clinical needs and facilitates care management through care coordination, clinical support, linkages to appropriate resources and other case management functions, as appropriate.

2. Develops an outcome-based plan of care, based on the member’s input and assessed member needs. Implements and evaluates the plan of care as often as needed as evidenced by documentation in the member’s case file.

3. Manages transition of care from the sending to receiving settings ensuring that the Plan of Care moves with the member and updates/modifies the care plan as the member’s health care status changes.

4. Documents member assessment and reassessment, member care plans, and other pertinent information completed in the member’s medical record in accordance with the FOCUS Charting methodology, nursing standards, and company policies and procedures.

5. Conducts community visits (hospital, home visits) as needed to assess patient progress, support care management and meet with appropriate members of the patient care team.

6. Identifies and addresses psychosocial needs of the members and family and facilitates consultations with Social Worker, as necessary.

7. Identifies and addresses pharmacological needs of the members and facilitates consultations with the pharmacy department, as necessary.

8. Identifies planned and unplanned transitions of care from Requests for Services or daily inpatient and SNF census.

9. Educates the member/caregiver on the transition process and how to reduce unplanned transitions of care.

10. Identifies community resources to address needs not covered by the member’s benefit plan, and coordinates member benefits as needed, with the health plan.

11. Identifies the appropriate members to participate in the interdisciplinary case round process. Prepares the necessary summary information to present to the team.

12. Responsible for the coordination of clinic appointments, medication reconciliation, PCP and SPC visits.

13. Responsible for the coordination and facilitation of member and family conferences as determined by assessment of member’s needs.

14. Collaborate and communicate with all members of the healthcare team (concurrent review, pre-authorization, PCP/SPC, Social Services, and Pharmacy) to coordinate the continuum of care of developing plans for management of each case.

15. Communicates appropriately and clearly with physicians, inpatient case managers and prior-authorization nurses. Interacts professionally with member/family/physicians and involves member/family/physicians in formation of the plan of care.

16. Keeps member/family members or other customers informed and requests if necessary, further assistance when needed.

17. Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.

18. Participates in the efficient, effective and responsible use of resources such as medical supplies and equipment.

19. Other duties as assigned by management.

1. Graduate from an accredited Registered Nursing Program.

2. Current CA RN license, current CPR certification, valid CA Driver’s license.

3. 3 years acute care or case management experience preferred.

4. 2-3 years of utilization or HMO experience preferred.

5. Must have valid CA DL and provide proof of vehicle insurance.

6. Knowledge of computers, faxes, printers and all other office equipment.

7. Typing 30 WPM with accuracy.

8. Proficient in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint).