performing care management within the scope of licensure for members with complex and chronic care needs
assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum
performs duties telephonically with medical groups, providers, community resources, and members for discharge planning
ensures member access to services appropriate to their health needs
conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment
implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements
coordinates internal and external resources to meet identified needs
monitors and evaluates effectiveness of the care management plan and modifies as necessary
interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans
assists in problem solving with providers, claims or service issues

Requires BA/BS in a health related field
minimum of 3 years of clinical experience
Current, unrestricted RN license in the state of California required
Case Manager experience within hospital or managed care setting is preferred
Clinical experience working with individuals with various chronic diseases, illnesses, and medical needs strongly preferred
Knowledge/experience with discharge planning preferred.

Nurse Case Manager – California HMO

Key skills