Job description

Full-Time
Monday - Friday 8:30 - 5:00
Salary: LVN $60,000 - $70,000
Education: Graduate from an accredited school of nursing LVN
Licenses: Current CA LVN (Must obtain current CA drives license)

Position Summary

The Case Management Nurse is responsible for providing an ongoing large portfolio of cases to support patients and quality assessments and performance improvement activities which include but are not limited to quality monitoring, evaluation, and facilitation of performance improvement projects. Assist and assess, develop, implement, coordinate and monitor a comprehensive plan of care for each patient/family in collaboration with physicians, social workers, and members of the team providing care to the patient. This position requires the ability to combine clinical/quality considerations with regulatory/financial/utilization review demands to assure patients are receiving care in the appropriate settings and level of care. This position creates a balance between individual clinical needs with the efficient and cost-effective utilization of resources while promoting quality outcomes. Gather and evaluate clinical data from the organization, analyzing data for patterns and trends in the delivery of healthcare, research root causes for specific patient care trends; training and educating staff to promote excellent quality practices, and ensure compliance with all applicable laws and regulations; work closely and collaboratively with leadership and staff to ensure data collected is in accordance with prescribed quality standards; HEDIS/RAF measures and internal protocols. Keeping up to date with all federal and state laws, regulations and requirements. Provide evidence-based care in a collaborative environment. As a case manager, you will work collaboratively with the clinical team to engage, educate, manage and coordinate care with patients and their family and behavioral health, medical providers. Provide community resources and ensure individualized service plans are implemented. You will perform all case management functions associated with a caseload of but not limited to 50 ongoing patients. As a case manager, you will provide continued coordination of care, clinical record documentation (Assessments, provision of services, and discharge planning) You will provide continuous evaluation of the effectiveness of treatment through the ongoing assessment of the client and from the input from the client and others resulting in modification to the service plans as necessary. Read and interpret patient information, ensuring excellent treatment plans. Research and implement healthcare processes and improve patient outcomes. Provide comprehensive management of high-risk patients with complex medical and psychosocial needs.

Qualifications

• Appropriate minimum degree for preferred licensure or certification or commensurate experience in a related healthcare field.
• Healthcare professional licensure is required as LVN required.
• Appropriate certification in Case Management is preferred; for example, Commission for Case Manager Certification (CCMC); Association of Rehabilitation Nurses (ARN) certification.
• Five years of experience in an acute care Medical/Surgical and/or ICU/CCU setting.
• Bachelor’s of Science or associate degree in nursing, healthcare/business administration, or equivalent experience
• Minimum of two years of clinical nursing experience
• Current unencumbered California LVN license
• Current Basic Life Support (BLS) for Healthcare Providers
• Minimum three years of three years work in a healthcare environment or equivalent managed care regulatory experience related to Case management Appeals, Grievances, Clinical Quality Coordination, Risk Management, Peer Review, and or Health Service Management
• Knowledge and understanding of Core Measures or other publicly reported quality metrics required
• Proficiency with Excel, MS office, data interpretation and demonstrates the ability to learn new information systems and software programs
• Required attention to detail, analytical thinking skills, excellent technical, interpersonal, and oral communication skills
• Experience in but not limited to Medicare and Medi-Cal (CMS) environment preferred
• Knowledge of basic statistics; HEDIS reporting or collection experience
• Ability to manage and maintain multiple projects, data input, strong problem-solving capabilities
• Working knowledge of medical terminology
• Knowledge of managed care, claims payments and processes with insurance terminology
• A minimum of 1 year of data collection, basic statistics and statistical measurement tools, and data analysis
• Excellent interpersonal and communication skills; verbal and written
• Strong organizational and time management skills required
• Must be able to show compassion, empathy, and be sympathetic with nonjudgmental treatment to patients and family or support teams.
• Must be able to use clinical skills to analyze, review and judge different situations patients face and take the required actions according to regulations and expectations, and ethical guidelines
• Excellent interpersonal, communication, and facilitation skills
• Experience with spreadsheets and word processing programs

Duties/Responsibilities

• Managing a portfolio of cases.
• Meeting with patients on a regular basis telephonically and or but not limited to telehealth.
• Establishing and maintaining effective relationships with patients, caretakers, family, and other support services.
• Proactively managing an ongoing caseload.
• Working in accordance with relevant legislation, health care best practices, and internal policy and procedure.
• Helping to manage patient health care needs and services in areas such as long-term care, mental health, substance abuse, and geriatric care.
• Work with clients to create a treatment plan.
• Work with each service provider on a discharge plan.
• Participate in departmental, agency, or hospital risk, safety, quality, and committee meetings
• Assist with claims, litigation, billing, insurance, and patient case management
• Collaborate and communicate with executives to ensure that and areas of concern are identified, documented, and resolved in a timely manner
• Assist with training key staff members responsible for safety and quality assurance
• Participate in continued education classes to maintain licensure and certification requirements
• Design and execute training programs designed to enhance health care professionals’ knowledge of risk management and quality improvement.
• Prepare formal responses, quality assessments, and risk management reports for administration regulatory agencies and other official parties.
• Work closely with all departments necessary to ensure that processes, programs, and services are established and accomplished in an effective and timely manner in accordance with health plan policies and procedures and ensure compliance with state and federal regulations including CMS and DHCS
• Analyze and perform quality assurance and data integrity, verify reports and data prior to submission
• Clear and effective understanding of prioritizing reports according to meet the needs of the departments, regulatory requirements, and urgency of any other key pr pressing business factors
• Provide ongoing case management to clients to meet their health care needs
• Assist patients, staff, and physicians to maintain a high level of efficiency of operations and care while providing quality care to the designated patient population
• Maintain an active caseload and meet regulatory expectations
• Advocate for patients and families with a point of care approach while guiding them through the healthcare systems while providing services, education, and access to care
• Maximizing care continuity and satisfaction.
• Build and maintain strong relationships with patients, physicians, and community resources to assure that there are multiple options for the patients
• Collect data regarding patient referrals, quality, and outcome to committees and organizations
• Support in training staff to reduce anxiety and frustration with coordinating care and improve patient satisfaction
• Ability to be innovative and creative in order to develop strategies and successfully meet the needs of diverse patient, family, and provider populations
• Demonstrate competence in team building, conflict management, and interpersonal effectiveness
• Addressing care coordination, resource management, prior authorization facilitation of referrals to providers and community resources and services.
• Meet the needs of the department

Optima Medical Management is an equal opportunity employer that is committed to diversity and values the ways in which are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, age, national origin, gender, gender identity, status as a protected veteran, among other things, or status as qualified individuals with disabilities or other characteristics protected by applicable law

Job Type: Full-time

Pay: $60,000.00 - $70,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Disability insurance
• Employee discount
• Flexible spending account
• Free parking
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Paid training
• Referral program
• Vision insurance

Physical setting:

• Outpatient

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Ability to commute/relocate:

• San Diego, CA 92123: Reliably commute or planning to relocate before starting work (Required)

License/Certification:

• LVN (Required)

Work Location: In person

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