Medical Case Manager

Work Arrangement: Full Office

Work Schedule: Monday through Friday; 8:00 a.m. to 5:00 p.m.

Expected Assignment Duration: up to six (6) months

Duties & Responsibilities

Medical Review Support -

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Reviews requests for medical appropriateness for CBAS services utilizing Medi-Cal criteria or established policies and procedures.
• Performs and/or reviews clinical assessments including California Department of Aging (CDA) approved standardized tools such as CBAS Eligibility Determination Tool (CEDT) and CBAS Individual Plan of Care (IPC).
• Determines the appropriate decision regarding the service being requested for approval, modification or denial, and refers to the Medical Director when necessary.
• Screens CBAS requests for Medical Director review, gathers pertinent medical information prior to submission to the Medical Director, communicates the Medical Director’s decision with the requestor and documents follow-up in the care management system.
• Initiates and follows through with contacting the member’s caregiver, family, CBAS provider and treating physician as needed to obtain additional information for utilization review.
• Complete all documentation accurately and appropriately for data entry in the care management system during authorization review, assessment and communication to include any authorization updates.
• Accurately codes each diagnosis of service and procedures according to the established policy and procedure.
• Analyzes all requests with the objective of monitoring utilization of services, which includes reviewing for medical appropriateness and identifying potentially high-cost complex cases requiring high-level case management intervention.
• Establishes a means of communication with other team members, Medical Directors, community support providers including CalAIM and IHSS, and skilled nursing facilities.
• Meets identified productivity and quality of work standards on an ongoing basis.
  
  

Minimum Qualifications

• Associate degree in Nursing (ADN) PLUS 3 years of nursing experience with the health needs of the population served; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
  
  

Preferred Qualifications

• 1 year of authorization review experience.
• Bilingual in English and in one of these languages: Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese
  
  

Required Licensure / Certifications

• Current unrestricted Registered Nurse (RN) license to practice in the state of California required.
  
  

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