Experience:
1-3 years of experience
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Employment Type:
Full time
Posted:
10/4/2016
Job Category:
Nursing
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Case Manager RN Rancho Cordova or Sacramento, CA 15+ Openings! #29201
Health Net, Inc. | Rancho Cordova, California
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Job Description

Job Summary

The Case Manager/Care Coordinator II is responsible for the coordination of services and cost effective management of health care resources to meet individual members' health care needs and promote positive health outcomes. Acts as a member advocate and a liaison between providers, members and HN to seamlessly integrate complex services. Case Management services are generally focused on members who fall into one or more high risk or high cost groups and require significant clinical judgment, independent analysis, critical-thinking, detailed knowledge of departmental procedures, clinical guidelines, community resources, contracting and community standards of care. Case Management includes assessment, coordination, planning, monitoring and evaluation of multiple environments.

Essential Duties & Responsibilities

  • Participates in programs to proactively identify members at risk who are appropriate for case management services.
  • Reviews, screens and prioritizes cases for possible case management services.
  • Expedites access to appropriate care for members with urgent or immediate needs using expedited review process.
  • Acquires appropriate clinical records, clinical guidelines, policies, EOC, Benefit Policy and coding guidelines.
  • Assesses the member's current health status, resource utilization, past and present treatment plan and services; prognosis, short and long term goals, treatment and provider options.
  • Develops plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs.
  • ·Works with the member/family, provider(s), and other members of the health care team to develop a plan of care that enhances the clinical outcome while maximizing the member's benefits.
  • Performs evaluation in multiple environments including process and relationships, health care management, community resource and support, service delivery, psychosocial intervention and rehabilitation.
  • Closes cases according to the defined case closure procedure in a timely manner, and in accordance with guidelines established.
  • Identifies potential reinsurance cases and notifies the appropriate department according to policy and procedure.
  • Identifies potential TPL/COB cases, investigate TPL/COB issues and notify the appropriate internal departments.
  • Identifies cases needing Medical Director review or input. Presents cases to Medical Director for potential review or determinations when needed.
  • Refers potentially inappropriate resource utilization or quality related concerns to Medical Directors.
  • Performs prospective, concurrent and retrospective reviews and first level determination approvals for assigned members, as appropriate, or refers reviews to appropriate associate.
  • Utilizes considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times and regulatory requirements.
  • Works closely with delegated or contracted providers, groups or entities (as assigned) to assure effective and efficient care coordination.
  • Maintains confidentiality of all PHI in compliance with state and federal law and Health Net Policy.

 

Education

  • One of the following required: Graduate of an accredited nursing program; or Bachelor's degree preferred

 

Certification/Licensure Required

  • Valid CA unristicted, current Registered Nurse License
  • Case Management certification preferred

Experience Required

  • Minimum three years clinical experience required
  • One to three years Case Management experience required
  • Health Plan experience preferred

 

Knowledge, Skills & Abilities

  • Strong knowledge of NCQA, federal and state regulations/requirements
  • Demonstrated ability for assessment, evaluation and interpretation of medical information, and care planning
  • Possess a high level of understanding of community resources, treatment options, home health, funding options and special programs
  • Extensive knowledge of the management of chronic conditions
  • Strong analytical and problem solving skills
  • Excellent verbal and written communications skills
  • Excellent case preparation and abstracting skills
  • Team player who builds effective working relationships
  • Ability to work independently
  • Experience using standardized clinical guidelines required
  • Strong organizational skills
  • Must be able to work well with all levels in the organization
  • Ability to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and Project
  • Ability to effectively analyze, interpret, apply and communicate policies, procedures and regulations
  • Local travel required

Working Conditions

  • The following section describes the general physical requirements for this position.  Please note that ‘constant’ refers to more than 81% of time; ‘significant‘ refers to 40-80%; and ‘moderate’ refers to 20-40% of the time.
  • Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
  • Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
  • May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
  • May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
  • Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
  • Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
  • Required to have hearing ability to receive detailed information through oral communication.
  • Required to have speaking ability to express or exchange ideas.
  • Constant concentration may be required on various subjects by listening, reading and thinking clearly.
  • Interaction with others may be required.  May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required.  This may require face-to-face or telephone interactions.
  • Thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next.
  • Constant computer usage including typing and/or eye strain. 
  • Constant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
  • Significant phone usage; headsets may be required.
  • Moderate travel may be required between work sites and/or out of area.
  • Moderate amount of time spent working in a loud office environment with frequent interruptions/distractions.
  • Constant sedentary work (desk bound or seated).
  • Constant reading is required via computer screen and/or bound printed materials.
  • Moderate walking/standing may be required.  Walking and/or transporting supplies and equipment between buildings/parking lots and structures may be required.

Disclaimer

DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified.

About Health Net, Inc.

Health Net, Inc. (Health Net) is an integrated managed care organization that delivers managed healthcare services through health plans and government-sponsored, managed-care plans. The Company operates and conducts its businesses through its subsidiaries. Health Net's health plans and government contracts subsidiaries provide health benefits through its health maintenance organizations (HMOs), insured preferred provider organizations (PPOs) and point-of-service (POS) plans to approximately 6.7 million individuals across the country through group, individual, Medicare, (including the Medicare prescription drug benefit commonly referred to as Part D), Medicaid, TRICARE and Veterans Affairs programs. The Company operates within two segments: Health Plan Services and Government Contracts. (Source: 10-K)

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