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Form of workThe Special Needs Plan Telephonic Case Manager acts as the point of contact providing care coordination to members designated by Health Plan Special Needs Plans (SNP). Utilizing the SNP Model of Care, the Case Manager is responsible for managing the medical, cognitive, psychosocial and functional needs of the member through the development of an individualized care plan with the member, which is reviewed by the Interdisciplinary Care Team (ICT).
- Responsible for telephonically monitoring Special Needs Plan (SNP) members by managing and educating them about healthcare conditions and prioritizing their healthcare needs, in order to prevent complications and avoid utilizations.
- Educate the member on the importance of following up with their Primary Care Provider (PCP) regularly, the use of Immediate Care (IC) facilities, and the Case Manager as the single point of contact, in order to prevent unnecessary utilizations.
- Serious Illness Discussions and Life Planning, such as POLSTS and DPOAs will be discussed with members regularly, and will also routinely address the importance of preventative care and the need for appropriate follow-up with those Health Care Professionals rendering health care with focus on needed quality measures.
- Will document effectively using the Problem, Intervention, Plan (PIP) format, in the Electronic Health Record (EHR) in a timely manner. This documentation must comply with nursing standards, company policies and procedures and the requirements mandated by health plans, CMS and NCQA in order to meet routine audits.
- Completes the Clinical Social Assessment (CSA) annually on all assigned members. The Case Manager determines an acuity score for necessary follow-up. The Acuity Score – 1, 2, or 3 is determined by identifying the member’s medical and social needs. The CSA will be updated as health care needs and conditions change.
- After completing the CSA with the member and obtaining their input and agreement; the Case Manager develops an individualized plan of care with goals that are Specific, Measurable, Attainable, Realistic, and Time Bound (S.M.A.R.T.) which address the goals the member wishes to work on, to include a self-management, goal oriented individualized care plan. The Individualized Care Plan will be updated as necessary as health care needs and conditions change and or on an annual basis.
- Collaborates with other members of the Interdisciplinary Care Team (ICT) to meet the needs and plan of care for the members.
- Actively seeks supervisory assistance by following the established departmental Chain of Command.
- Maintain a caseload of approximately 150-175 members.
- Achieve an overall audit-accuracy rating standard of 85% or better.
- Perform other duties as assigned.
- Completion of an accredited nursing program. Current California Licensed Vocational Nurse (LVN) or Registered Nurse (RN) License.
- 1 year of nursing experience that involves direct patient care in a hospital or skilled nursing facility setting.
- Strong medical knowledge and competence in chronic disease pathophysiology, polypharmacy, clinical assessment, and patient-family education.
- Excellent oral and written communication skills, conflict resolution, and time management and negotiation skills. Basic computer skills required.
- Ability to work independently with a minimum of direction on a high volume caseload environment and deal effectively with rapidly changing priorities. Ability to anticipate/organize workflow, prioritize and follow through on responsibilities.
- Positive interpersonal, influencing and decision making skills. Ability to work constructively with a broad spectrum of health care professionals, ability to work respectfully and creatively with members of diverse functional abilities, social, economic, and cultural backgrounds to support both member autonomy and member safety
- Bilingual preferred. Ability to speak, read and write in English and Spanish fluently, preferred.
- At the discretion of DOHC/FHC management, this position has the potential to be a full or hybrid telecommuting position.
