High Intensity Case Manager, RN

Job Description

The scope of the High-Risk Case Manager (HICM) is to effectively manage members on an outpatient basis to ensure the appropriate level-of-care is provided for complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care to prevent re-admissions and ensure that the members’ medical, environmental, and psychosocial needs are optimize over the continuum of care.

Responsibilities

• Identifies appropriate members for case management (CM) and conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
• Develop Individual Care Plan (ICP) by conditions identified in health plan HRA, patient assessment, medical records authorizations/referrals, primary care physician, member, and Interdisciplinary Care Team (ICT). Setting members prioritized and self-management goals.
• Case Manager’s ability to effectively manage a panel/caseload of high-risk members in collaboration with Nurse Practitioner, Pharmacist, PCP, SPC, health plans and other ICT members
• Create cases in Essette for each case managed member with appropriate documentation including but not limited to; cognitive, functional, ADL, environmental factors, psychosocial, medical and benefits etc.
• Provides appropriate documentation including but not limited to; cognitive, functional, ADL, environmental factors, psychosocial, medical and benefits etc.
• Collaborate with member’s family and physicians for seamless coordination of care and services
• Collaborate and coordinate care with Health plans, Community Based Programs (CBAS), Managed Long Term Supportive Services (MLTSS) and Behavioral Health Providers
• Monitors and evaluate effectiveness of the care management plan and modify as necessary based on members’ progress, changes in condition and to minimize unnecessary utilizations, admissions, and readmissions.
• Interfaces with Medical Director and attends ICT as required.
• Conducts outbound calls to assigned case management members. Occasional, in person visit may be needed to better facilitate members’ care.
• Collaborate with member, member’s family, and physicians for seamless coordination of care and services.
• Collaborate and coordinate care with health plans, Community Based Programs (CBAS), Multiple Long Term Support Services (MLTSS) and Behavioral Health providers.
• Meet health plans and NCQA requirements in turn-around-time for assessments, care plans and IDTs.
• Provide oversight and sign-off of care plans created by LVN case managers per company policy and health plan requirements.
• Triaging of incoming CM referrals, assess members immediate needs and assigning of case management level.
• Assist and provide guidance to LVN case managers in managing complex cases when needed.
  
  

Qualifications

Minimum Education: BSN preferred.

Minimum Experience: At least two (2) years’ experience in the medical field required. One (1) year experience in a case management role required. At least two (2) years’ experience in ambulatory case management, preferably in a managed care organization, medical group, or health plan setting required. Knowledgeable in NCQA requirements preferred.

Req. Certification/Licensure: RN unrestricted active license required. CCM Certification preferred.

"Location-Based Pay Adjustment"

About Us

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.