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Case Management - Health Insurance
Woodland Hills, CA
• Works with Members and their families to understand the illness or injury and collaborates to develop individualized care plans with healthcare goals that aim to produce the best health outcomes for the Member.
• Develops and implements Member centric interventions based on accurate assessments of the Member’s physical, functional, behavioral, and social needs, and current or proposed treatment plans in accordance with evidence based and clinical practice guidelines.
• Demonstrates sound clinical judgment and independent analysis to identify and navigate barriers that may prevent Members from achieving their healthcare goals.
• Applies detailed knowledge of established medical and departmental policies, clinical practice guidelines, community resources, and contractual and community care standards.
• Works with medical groups and individual providers to ensure continuity of care and implement effective discharge planning activities appropriate for the member’s needs.
- Working with complex cases promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits.
- Works with other members of team, provider, hospitals, IPA/MGs, members and their families to plan and review medical necessity, intensity of services, level of care, length of stay and general appropriateness of care.
- Provides guidance to the provider network.
- Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care.
- May provide case management to member segments with chronic or catastrophic illness.
Education and Credentials
• Current, Active, Unrestricted California Registered Nurse License required
• Bachelors of Science in Nursing or advanced degree preferred.
• Certified Case Manager (CCM) preferred or obtained within two years of hire. Experience:
• Requires 5-7 years of nursing experience, health care, or related field, with 3 years managed care experience preferred.
• Demonstrated competence in Case Management in accordance with CMSA Standards of Practice for Case Management.
• Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
• Understanding of community resources, treatment options, home health, funding sources and special programs.
• Knowledge of evidenced based clinical practice guidelines particularly for chronic conditions.
• Knowledge of Prior Authorization, Utilization Management, levels of care, and length of stay criteria preferred.
• Knowledge of regulatory/accreditation standards desirable (URAC, NCQA, DMHC, CMSA).
• Strong written and verbal communication skills with ability to advocate and negotiate on behalf of the Member. Bilingual preferred.
• Strong clinical documentation skills, independent problem identification and resolution skills.
• Ability to work with minimal supervision and demonstrate professional judgment and critical thinking when advocating for medical necessity that promotes quality, cost-effective care.
• Demonstrates cultural competence and understanding and respect for the beliefs, value systems, and decisions of the Member.
• Understanding of the Member’s right to self-determination as it relates to the ethical principle of autonomy.
• Proficient in software programs including Microsoft Office (Word/Outlook/Excel).