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

• 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.
• Communicates clearly and effectively through all mediums of communication with members, providers, vendors, community partners, and PHC 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 PHC
• 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 PHC 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 PHC’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 PHC policy are required to operate a vehicle and travel

for company business. Bilingual skills in Spanish, Russian, or Tagalog

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:

$49.54 - $64.41

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