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The Complex Case Manager Nurse will provide case management services for health plan
members with highly complex medical and psychiatric conditions where advocacy and coordination
are required to help the member reach the optimum functional level and autonomy. The Complex
Case Manager Nurse will be working closely with a team comprised of the Complex Case Manager
Nurse, a Medical Social Worker and a Health Navigator. This collaborate team approach to case
management will include key departments at the health plan, including Utilization Management and
Pharmacy, which may provide clinical expertise and data on patient utilization patterns, often in real
time, to the program. Externally, the team will work closely with community partners to make
referrals for care and resources and to best manage members across the care spectrum and among
multiple health care systems. The goal of the Complex Case Manage program is to improve
members' quality of life and assure cost-effective outcomes by utilizing all available and appropriate
Principal responsibilities include:
¿ Perform the primary functions of assessment, planning, facilitation and advocacy through
collaboration with the member and other health care resources involved in the member's
¿ Work closely with licensed and unlicensed staff to co-manage the care of complex cases
telephonically through regular contact with members, caretakers, healthcare
professionals and others involved in the member's care
¿ Carry a caseload of members individually and co-managed as a team
¿ The nurse will act a subject matter expert on the nursing process and perspective for the
¿ The nurse will be responsible for triage and all aspects of the nursing process, including
assessing, diagnosing, planning, implementing, and evaluating care.
¿ Develop multi-disciplinary care plans with the input of the member and PCP to address
identified member problems using evidence-based goals and interventions
¿ Participate in the ongoing process of a identifying the health plan's members who are
most at-risk of poor health outcomes and in need of care management services.
¿ Participate in weekly Multidisciplinary Care Team Meetings and be able to present
compel medical cases before the department wide team
¿ Work collaboratively with health plan's providers, particularly member's primary care
providers and specialist, in order to provide highly coordinated and often specialized
¿ Assess member medical and social determinants of health and
¿ Communicate with providers, members, and community resources as necessary, to
support the planning, implementation and evaluation of care management programs.
¿ Employ a patient advocacy approach with a seamless integration of services is required
and must be balanced within the member's benefit structure.
¿ Complete other duties and special projects as assigned.
¿ Communicate and coordinate required services for members with PCP's and specialists.
¿ Manage, document, and maintain casework in accordance with NCQA accreditation guidelines
and state regulators.
¿ Build and maintain effective relationship with designated members and those members' families
¿ Maintain case management records.
¿ Develop appropriate member care plans and appropriate member assessments.
¿ Serve as a clinical resource to staff, as needed.
¿ Perform writing, administration, analysis, and report preparation.
¿ Research and develop working relationships with appropriate community resources to
¿ Provide direction to ancillary team/pod staff members who will provide additional
coordination activities for health plan members being case managed.
¿ Comply with the organization's Code of Conduct, all regulatory and contractual
requirements, organizational policies, procedures, and internal controls.
¿ Constant and close visual work at desk or computer.
¿ Constant sitting and working at desk.
¿ Constant data entry using keyboard and/or mouse.
¿ Frequent use of telephone headset.
¿ Frequent verbal and written communication with staff and other business associates by
telephone, correspondence, or in person.
¿ Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
¿ Frequent walking and standing.
EDUCATION OR TRAINING EQUIVALENT TO:
¿ BSN or MSN required.
¿ Registered Nurse license, active and unrestricted licensed in the State of California
before start of work.
ESSENTIAL FUNCTIONS OF THE JOB
Number of Employees Supervised: 0
¿ Current CPR and first aid card prior to or within six months of hire is preferred.
¿ Certification in case management (CCM etc.) preferred or willing to become certified
within 12 months of hire or a date agreed to by supervisor.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
¿ Three years experience in clinical case management required
¿ Three years of clinical experience in an acute care setting desired
¿ Masters in Case Management will be considered in lieu of clinical acute experience
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
¿ Excellent verbal and written communications skills.
¿ Knowledge of Medi-Cal and Medicare regulations a plus.
¿ Ability to motivate.
¿ Knowledge of and experience with community and other resources a plus
¿ Ability to prioritize case load.
¿ Experience in use of Windows including Microsoft Office suite.
¿ Experience in use of Care Management Software applications
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