Care Management Specialist II, D-SNP Team Job at L.A. Care Health Plan (Los Angeles)

Job Description

The Care Management Specialist II utilizes clinical skills and training to perform essential functions of care management for identified and assigned member population according to Health Insurance Portability and Accountability Act (HIPAA) guidelines.

Job Responsibility

Utilizes clinical skills and training to perform essential functions of care management for identified and assigned member population according to Health Insurance Portability and Accountability Act (HIPAA) guidelines
Manages a specified caseload across the entire continuum of programmatic levels including those within National Committee for Quality Assurance (NCQA) scope or otherwise Complex/Catastrophic cases
Management of the caseload assigned by Manager includes: coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner
Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefit
Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team
Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines
Uses claims processing and care management software to look up member information, document contacts, and track member progress
Applies clinical knowledge and experience to evaluate information regarding prospective care management members referred by health risk assessment (HRA), risk stratification, predictive modeling, provider’s utilization review vendors, members, Call Center, claims staff, Health Homes Program (HHP) eligibility or other data sources to determine whether care management intervention is necessary to meet the member's needs
Conducts Care Management services for the most complex and vulnerable members including: engaging in member centric communication which includes the interdisciplinary team, providers and family or authorized representatives
reviewing member claims histories and identifies intervention opportunities through the professional standards of practice
contacting and interviewing members to conduct a baseline assessment, assess self-care ability, assess knowledge and adherence deficits
conducting comprehensive clinical assessments as indicated
developing a member centric plan of care
Maintains assigned care management caseload for with a focus on the most complex, highest-risk members particularly those with advanced chronic conditions, co-occurring mental and/or substance abuse and complex social issues (e.g. homelessness, domestic violence)
Collaborates with primary care physician and other treating professionals as appropriate
Authorizes initiation of care management services and specialized program services for members and specific populations, and develops interventions designed to meet member or population desired outcomes
Provides comprehensive education and resources to members about accessing services, in-network use, national guidelines for care, community resources, and self-management skills and strategies
Employs engagement techniques to build relationships with members and their authorized representatives
Encourages participants to participate in their health care decisions and assists member with researching treatment options in order to communicate effectively with providers and to make informed decisions
Notifies Care Coordinators and CHWs of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines
Performs field assessment and care coordination functions in community settings with members, such as at the L.A. Care Community Resource Centers, medical clinics, and member homes
Meets and assesses members at L.A. Care Community Resource Centers, as needed
Provides effective care management for Individualized Care Plan summary and interventions during the Interdisciplinary Care Team meetings based on department guidelines
Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care
Identifies member needs for and refers to appropriate internal and external programs, as appropriate
Encourages member and family empowerment through education and use of reliable resources
Monitors and evaluates member progress: evaluates member response to interventions and refines action plan to produce desired outcomes
Identifies complex care management issues and discusses possible solutions with management
Assesses effectiveness of care plan’s goals and interventions on a regular basis
Uses claims and care management software to document interactions and interventions with members, vendors, and providers
Maintains case information in the member's clinical records to promote care coordination
Provides ongoing direction and support to internal customers regarding Care Management programs, processes, and benefit coverage
Responsible for staying current with best practices, identifying areas for personal growth opportunities and works with management to develop a plan for obtaining the necessary training
Performs other duties as assigned

Requirements

Associate's Degree in Nursing for Registered Nurses OR Master's Degree in Social Work for Licensed Clinical Social Workers
Minimum of 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments
Experience providing care management with complex/catastrophic conditions
Current knowledge of clinical standards of care and disease processes
Critical thinking skill
Excellent customer service skills
Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine and implement the most effective member-centered interventions
Ability to triage immediate member health and safety risks
Ability to sensitively manage member or family responses associated with high acuity cases and support effective coping
Strong verbal and written communications skills to consult effectively with interdisciplinary teams, coordinate care with members and their families, and other internal and external stakeholders
Ability to use a personal computer, and knowledge of medical information systems
Knowledge of and ability to comply with HIPAA compliance
Ability to interview, assess and coordinate care
Ability to prioritize caseload
Knowledge of community resources
Knowledge of Medi-Cal and Medicare regulations
Ability to work as a part of a diverse team and gain consensus and resolution of problems
Registered Nurse (RN)
current and unrestricted California License OR Licensed Clinical Social Worker
current and unrestricted California License
Travel to offsite locations for work

Nice to have

Bachelor's Degree in Nursing for Registered Nurses
Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese
Certified Case Manager (CCM)
Accredited Case Manager (ACM) Certification
Case Management Nurse – Board Certified (CMGT-BC)

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

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Care Management Specialist II, D-SNP Team

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