Clinical Services Nurse Outreach

Primary Purpose:

To provide support and facilitate care for members who require case management. To work collaboratively with the Health Plan and Hospital Case Management Departments to facilitate services. To collaborate with the treating physician and IPA Medical Director in the review and decision-making process regarding the provision of appropriate health care and service requests. Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates an individual’s health needs through communication and available resources to promote quality and cost-effective outcomes. 

The CM will coordinate care for Cal Medi-Connect program members to ensure that all aspects of the DSNP program description are implemented and followed. 

All services under Medicare and Medi-Cal will be coordinated and monitored, including CCS, IHSS, CBAS, and BH. The case manager is a licensed nurse (RN or LVN). A care manager can be a licensed social worker (MSW) or a licensed nurse (RN or LVN). 

All candidates for any position within case management will have the appropriate education and experience to meet requirements and the service needs of the population. 

Principal Duties and Responsibilities (* = essential functions):

• To utilize the Case Management functions: assessor, planner, facilitator, and advocate. *
• To facilitate services at the appropriate Health Plan center of excellence. *
• To review and process clinical information in accordance with regulatory mandates to facilitate patient healthcare and services across the continuum of care. *
• To perform case management as appropriate to the patient’s medical condition and healthcare needs, utilizing the standards of practice for Case Management.
• To interface professionally and courteously with all internal staff and external customers to ensure appropriate exchange of information. *
• Preparing for and participating in health plan audits as required.
• To actively participate in Utilization Management meetings regarding Case Presentations and problem-solving.
• To participate in the development of Case Management Policies and Procedures.
• To actively participate in the discharge planning process.
• To monitor and participate in the SNP/Duals program
• To follow the UM/QI/CM/SNP/CMC program descriptions 
• To perform other duties as assigned.

Job Specifications (KSAs):

• Requires extensive and specialized knowledge of utilization and case management processes, generally acquired through 2-3 years or more of experience as a case manager in a Managed Care Environment, or through successful completion of a nursing program.
• Requires prior Case Management experience
• Requires an active RN or LVN license in the state of employment.
• Requires clinical expertise, generally acquired through 3 to 5 years of acute nursing practice.
• Requires excellent written and verbal communication skills.
• Requires computer experience, particularly with Microsoft Word and Excel, familiarity with Cozeva (a plus), and the ability to learn new software applications quickly.
• Requires problem-solving and critical thinking skills.
• Requires professional demeanor and the ability to contribute to a positive work environment.
• Requires knowledge of regulatory standards such as Medicare, TitleXXII, and Medi-Cal*
• Requires extensive knowledge of health plan guidelines.

Position Performance Criteria:

1. Demonstrates proficiency in UM and Case Management, including but not limited to:

• Complex Case Management
• Transplant Management
• Referral review
• Out-of-network management

1. Demonstrates the effective practice of Case Management Standards of Care, including: 

• Assessment
• Case Identification and Selection
• Planning
• Monitoring
• Evaluating 
• Outcomes

1. Sets appropriate priorities to meet departmental goals and objectives, including but not limited to:

• Demonstrates ability to efficiently manage case load.
• Demonstrates ability to set appropriate priorities
• Consistently makes prudent and sound decisions
• Manages multiple tasks while meeting required timeframes
• Adheres to departmental policies and procedures

1. Demonstrate knowledge of Health Plan guidelines.
2. Demonstrates knowledge of federal, state, NCQA, and health plan regulatory requirements and approved criteria guidelines.

• Ensures consistency in the application of the utilization process.
• Maintains knowledge of new legislation and disseminates information to providers and co-workers.

1. Demonstrates ability to give concise, articulate, and accurate case presentations to Medical Director, UMC, etc., including problem-solving.
2. Consistently demonstrates professional work ethic, collegial interaction with others, and reliability, while contributing to a positive work environment, including but not limited to:

• Professional appearance and demeanor
• Meets departmental attendance needs on site
• Participates verbally in group activities, i.e., staff meetings, etc.
• Demonstrates respect for co-workers and customers.
• Works collaboratively with other departments to identify and resolve issues.