Complex Care Manager - RN
On-siteLong Beach, California, United States
Job Summary
Assess members to identify medical, physical, and psychosocial needs, then evaluate clinical appropriateness of care plans against evidence-based guidelines. Provide effective case management by identifying barriers to adherence and modifying plans with members to ensure goals are met. Educate members on health prevention and disease states, while facilitating care coordination across the continuum and connecting families with community resources. Document accurate data for all contacts in the appropriate database and address identified quality concerns using approved processes. Actively participate in staff and interdisciplinary team meetings to enhance department reputation and serve as a resource for other departments.
Required Qualifications
- Bachelor's degree from a four year college in nursing or related field
- Current and active California RN License (Graduation from an accredited school of nursing)
- 3 - 5 years of clinical experience with geriatric population (Acute, Ambulatory care, SNF and/or LTC)
- Medicare/Medi-Cal experience in managed care environment
- Basic knowledge of related NCQA standards, CMS and DHCS regulations
- Navigate and access multiple software systems without error
- Proficient in MS Office Suite
- Medical and clinical terminology conversant
- Meets core competencies and clinical skill set for entry level Basic ICD-9/10 and CPT coding knowledge
Desired Qualifications
- 2+ years of case management experience in a medical group, IPA and/or HMO setting
- Case Management Certification (CCM), Accredited Case Management (ACM) or Certified Professional of Utilization Management (CPUM)
- Proficiency in second language (includes, but not limited to, Korean, Spanish, Tagalog, Chinese, Vietnamese, Farsi, and Russian)
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