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Form of workSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
Job Summary
The Enhanced Care Management (ECM) Clinical Specialist II is responsible for the management and oversight activities associated with L.A. Care's ECM network. The position reports to the Supervisor of ECM and receives clinical supervision as needed from the Medical Director of Care Management. The position is responsible for providing oversight, feedback, and technical assistance to ECM Providers to support effective delivery of ECM services and ensure compliance with local, State, and Federal regulations, statues and guidelines. The position is responsible for conducting regular meetings with providers, reviewing Assessments & Care Plans, providing guidance on clinical best practices, and assisting with escalation of cases that require additional assistance from L.A. Care. The position works directly with Care Management and Provider Network Management staff to inform Provider capacity-building and training activities related to the ECM Program operations.
Duties
Conduct regular monitoring and coaching with Providers to review aggregate progress and individual ECM member cases. May use telephonic, onsite, or written methods and both group and individual Provider activities to monitor performance related to Provider clinical and service requirements. Provide guidance on best practices to ECM providers.
Conduct a monthly random sample review of Assessments and Care Plans created by the ECM Provider. Identify any gaps in the Care Plan services or regulatory compliance and provide coaching and feedback to the Provider to improve. Identify any issues that require escalation or more frequent monitoring of the ECM Provider. Organize and perform file review process in accordance with given criteria to include collection & verification of supporting documentation, recording received information in appropriate tracking systems, and communicating end results of requests in writing and/or verbally.
Provide training, education and consultation as necessary to Providers. Collaborate with other ECM staff on identifying topics and developing materials for Provider training and capacity building.
Assist ECM Providers with escalation of ECM member cases that require additional assistance from L.A. Care.
Assist ECM Providers with the coordination of member care with internal L.A. Care departments such as Care Management (CM), Utilization Management (UM), Managed Long Term Services and Support (MLTSS), Social Services, Behavioral Health, Community Health, Health Education, as well as external providers such as Participating Physician Groups (PPGs) and Primary Care Physicians (PCPs).
Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of ECM. Assist co-workers with special projects or work volume as required. Communicates any barriers to supervisors in an efficient and effective manner.
Perform other duties as assigned.
Duties Continued
Education Required
Associate's Degree in Nursing
Master's Degree in Social Work for Licensed Clinical Social Workers
Education Preferred
Bachelor's Degree in Nursing
Experience
Required:
Minimum 3 years of recent Care Management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments.
Previous Care Management experience to include auditing/oversight/performance management experience.
Working knowledge of Medi-Cal and Medicare regulations.
Skills
Required:
Current knowledge of clinical standards of care and disease processes, and community resources.
Excellent verbal and written communicating skills; excellent interpersonal skills.
Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine the most effective member-centered interventions.
Proficiency in Microsoft Office MS Office applications.
Maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.
Ability to solve complex issues and identify creative solutions with external agencies.
Excellent project management skills.
Preferred:
"Bilingual in one of LA Care Health Plan's threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese".
Licenses/Certifications Required
Licensed Clinical Social Worker (LCSW); Current and unrestricted California License or Registered Nurse (RN); current and unrestrited California License.
Licenses/Certifications Preferred
Certified Professional in Utilization Review (CPUR)
Certified Case Manager (CCM)
Required Training
Physical Requirements
Light
Additional Information
Preferred:
Certification in Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), Utilization Management or Compliance
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
Job Summary
The Enhanced Care Management (ECM) Clinical Specialist II is responsible for the management and oversight activities associated with L.A. Care's ECM network. The position reports to the Supervisor of ECM and receives clinical supervision as needed from the Medical Director of Care Management. The position is responsible for providing oversight, feedback, and technical assistance to ECM Providers to support effective delivery of ECM services and ensure compliance with local, State, and Federal regulations, statues and guidelines. The position is responsible for conducting regular meetings with providers, reviewing Assessments & Care Plans, providing guidance on clinical best practices, and assisting with escalation of cases that require additional assistance from L.A. Care. The position works directly with Care Management and Provider Network Management staff to inform Provider capacity-building and training activities related to the ECM Program operations.
Duties
Conduct regular monitoring and coaching with Providers to review aggregate progress and individual ECM member cases. May use telephonic, onsite, or written methods and both group and individual Provider activities to monitor performance related to Provider clinical and service requirements. Provide guidance on best practices to ECM providers.
Conduct a monthly random sample review of Assessments and Care Plans created by the ECM Provider. Identify any gaps in the Care Plan services or regulatory compliance and provide coaching and feedback to the Provider to improve. Identify any issues that require escalation or more frequent monitoring of the ECM Provider. Organize and perform file review process in accordance with given criteria to include collection & verification of supporting documentation, recording received information in appropriate tracking systems, and communicating end results of requests in writing and/or verbally.
Provide training, education and consultation as necessary to Providers. Collaborate with other ECM staff on identifying topics and developing materials for Provider training and capacity building.
Assist ECM Providers with escalation of ECM member cases that require additional assistance from L.A. Care.
Assist ECM Providers with the coordination of member care with internal L.A. Care departments such as Care Management (CM), Utilization Management (UM), Managed Long Term Services and Support (MLTSS), Social Services, Behavioral Health, Community Health, Health Education, as well as external providers such as Participating Physician Groups (PPGs) and Primary Care Physicians (PCPs).
Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of ECM. Assist co-workers with special projects or work volume as required. Communicates any barriers to supervisors in an efficient and effective manner.
Perform other duties as assigned.
Duties Continued
Education Required
Associate's Degree in Nursing
Master's Degree in Social Work for Licensed Clinical Social Workers
Education Preferred
Bachelor's Degree in Nursing
Experience
Required:
Minimum 3 years of recent Care Management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments.
Previous Care Management experience to include auditing/oversight/performance management experience.
Working knowledge of Medi-Cal and Medicare regulations.
Skills
Required:
Current knowledge of clinical standards of care and disease processes, and community resources.
Excellent verbal and written communicating skills; excellent interpersonal skills.
Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine the most effective member-centered interventions.
Proficiency in Microsoft Office MS Office applications.
Maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.
Ability to solve complex issues and identify creative solutions with external agencies.
Excellent project management skills.
Preferred:
"Bilingual in one of LA Care Health Plan's threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese".
Licenses/Certifications Required
Licensed Clinical Social Worker (LCSW); Current and unrestricted California License or Registered Nurse (RN); current and unrestrited California License.
Licenses/Certifications Preferred
Certified Professional in Utilization Review (CPUR)
Certified Case Manager (CCM)
Required Training
Physical Requirements
Light
Additional Information
Preferred:
Certification in Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), Utilization Management or Compliance
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
