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Case Management Intermediate
Ref No.: 18-00273
Location: San Francisco, California
Start Date: 04/03/2018
 Case Management Intermediate- San Francisco, CA- Contract to hire opportunity!
Day to Day Responsibilities of this Position and Description of Project:

Responsibilities:
Researches and designs treatment /care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type. Implements discharge (DC) planning activities for medically complex cases. Determines appropriateness of referral for CM services. Provides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD). Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases. Manages member treatment to meet recommended length of stay. Ensures DC planning at levels of care appropriate for the members needs and acuity.
Assessment: Assesses members health behaviors, cultural influences and clients belief/value system. Evaluates all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers. Researches opportunities for improvement in assessment methodology and actively promotes continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and our company.
Planning: Designs appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes. Adjusts plans or creates contingency plans as necessary. Assesses and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settings. Develops appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Recognizes need for contingency plans throughout the healthcare process. Develops and implements the plan of care based on accurate assessment of the member and current or proposed treatment plan.
Member Advocacy: Advocates understanding and respect for the beliefs, value system, and decisions of the client. Recognizes the clients right to self-determination as it relates to the ethical principle of autonomy, including the client/family right to make informed choices that may not promote the best outcomes, as determined by the healthcare team. Advocates and strives to achieve consensus among all parties to promote positive client health and wellness outcomes. Represents the clients’ interests by advocating necessary funding, appropriate treatment and treatment alternatives, timely coordination of health services, and frequent re-evaluation of progress and goals.
Additional Transplant CM Duties: Provides clinical input to medical directors. Conducts assessment and quality reviews of the transplant network Current knowledge of transplant service trends. 

Education/Requirements:
Current CA RN License. Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning. In depth understanding of community resources, treatment options, home health, funding sources and special programs. Extensive knowledge of evidenced based clinical practice guidelines particularly for chronic conditions. Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, Case Management Society of America CMSA) Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable. Demonstrated and evolving competence in CM functions and standards of practice
Minimum Experience Level: Active CA RN License. Requires extensive experience in nursing, health care or related field (5-7 years). 3+ years managed care experience preferred. Able to operate PC-based software programs including proficiency in Word and Excel.

Cross Arthroplasty Program:
•Familiarity with medical / surgical orthopedics a plus.
•Experience interfacing with clinical personnel, i.e. provider offices, clinical staff, administrative personnel.
•Ability to manage CM files as well as capture the data for statistical purposes.
Required Skills (Top 3 to 5):  
1. Case Management (computer style) CCM certified preferred, Utilization Management a plus, Appeals and Grievance Experience a plus  
2. Health Plan and/or Medical Group experience  
3. Computer skills - Outlook, Basic Microsoft skills MUST be able to type. Excellent documentation skills  
4. Telephonic experience -  Call Center atmosphere  
5. RN License in CA required