Description
The Care Management Specialist is primarily responsible for the overall coordination of the Medicare-SNP program for Health Plan members. Responsibilities include program development, technology implementation and integrity, ensuring regulatory and accreditation compliance, program utilization and outcome reporting. The position is also responsible for assuring all functions are operating in accordance with the organization's mission, values and strategic goals; are focused on continuous improvement and provided in a manner that is responsive and culturally sensitive to the needs of our diverse membership.
The Care Management Specialist is responsible for the day to day referral management request for the Medicare-SNP program. This includes the timely and accurate determination and notification of pre-service, concurrent and retrospective referral requests; Generation of the CMS specific member communications.
In collaboration with the Primary Care Provider (PCP) and other treatment professionals, performs telephonic physical, functional and psycho-social assessments, assesses readiness to change, develops and maintains a member/family specific individualized care plan developed using evidenced based guidelines, approved clinical practice guidelines or protocols to determine variance from expected outcomes, linking member/family to resources within and outside the health care system and community, and researches all potential resources if gaps exist for that member within their service continuum, continuously maintaining an advocacy position.
The Care Management Specialist is the consistent person responsible for supporting and managing members or the member's representative through planned and unplanned transitions of care settings. The Care Management Specialist may also provide back-up care management support for the other direct lines of business and members as needed.
SKILLS:
EDUCATION
- Required Associate's or Bachelor's Degree in Nursing
- Preferred Master's Degree in Nursing, Health Administration, Public Health or related healthcare field.
Required
- Previous Care Management experience
- Utilization Management/Case Management experience 3-5 years
- HMO managed care (Health Plan or Medical Group) with prior experience in ambulatory case management, disease management, case management, complex case management, catastrophic case management, or any combination of education/experience which would provide an equivalent background
- Strong clinical skills with a knowledge of behavioral assessment techniques
- Knowledge of health and/or patient education and behavioral change techniques
- Excellent interpersonal and communication skills good
- Computer literacy and adaptability to computer learning; time management and priority-setting skills and proficiency in Microsoft Office (Excel, Word, Access, etc.).
- Experience working with the Medi-Cal and Medicare populations
- Experience in rehabilitation therapies (inpatient or outpatient); experience in working and referral to community based organization.
- Good working knowledge of regulatory requirements/standards including NCQA QI7 (Complex Case Management) standards.
Required
- Current, active, unrestricted California Registered Nurse license
- Valid California Driver's License
- Case Management Certification; Public Health Nursing certification; Certified Nurse Practitioner
- Preferred Spanish