Nurse Case Manager Ii

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.

In addition to the Care Coordination Case Manager I duties, the Care Coordination Case
Manager II has a higher level of experience, evaluates special requests, assists benefit
interpretation, serves as a liaison between the line staff and the supervisor, participates in audit
activities and shows initiative improving processes.

• Provides case management services independently for a caseload ranging in complexity
  from basic to complex; acuity levels 1-5 independently, including field-based case
  management as appropriate per case needs.
• 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 independently distributes department
  referrals, in accordance with identified department service levels.
• Collaborates and coordinates with internal departments and external agencies to identify
  members suitable for case management.
• Actively participates in essential skills training, unit and departmental assigned learning,
  and other departmental activities as assigned. In addition, identifies and attends at least 8
  hours/year of additional training/development activities designed to enhance
  performance and or clinical expertise (i.e. LMS, Case Management Certification course
  work, provider-led conferences, etc.).
• Develops and leads trainings for onboarding new staff and ongoing department needs, in
  collaboration with other PHC staff
• Completes internal case audits and provides support and guidance to clinical and nonclinical staff in accordance with identified department guidelines. Performs quality
  audits on external vendor/delegated entity activities in accordance with department
  standards.
• 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.
• Monthly Audit of triage reports from delegated 24-hour nurse triage line.
• 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.

Education and Experience

Associate’s degree in Nursing required; Bachelor’s degree in Nursing
(or higher) preferred. 3 years of cumulative case management
experience required, or equivalent combination of education and
experience. General knowledge of managed care and/or experience
with Medicaid population preferred.

Special Skills, Licenses andCertifications

Current unrestricted California Registered Nurse License. Thorough
knowledge of utilization and case management programs, criteria, and
protocols. Certification in case management (Commission for Case
Management (CCM), Board Certification in Case Management (RNBC), Public Health Nurse Licensure, or advanced nursing licensure, or
other certification demonstrating appropriate essential skills is
preferred. 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. Ability to apply
clinical judgment to complex medical situations and make quick
decisions. 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 the 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 10lbs.

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:

$ 50.40 - $ 65.52

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