Medical Case Manager (MSSP)
CalOptima is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto — “Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health. If you’re looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima.
The Medical Case Manager, Multipurpose Senior Service Program (MSSP) facilitates communication and coordination among the health care team to ensure services are provided to promote quality cost-effective outcomes for the member. The incumbent provides case management interventions on behalf of older adult members living in the community with significant medical or caregiving deficits and at risk of further deterioration and/or institutionalization. The primary responsibilities for the Medical Case Manager (MSSP) include ensuring the medical appropriateness, quality, and cost-effectiveness of proposed hospital/medical/surgical services within established criteria. The incumbent evaluates each member as a total person and identifies the functional and health limitations impeding safe independent living.
• Conducts in-field, virtual, or telephonic assessments of each member’s current status including the physical, psychosocial, and environmental conditions.
• Navigates the sensitivities of completing care management work in the private residences of members.
• Builds and maintains rapport with members from diverse backgrounds to foster effective care management relationships that will support the member’s coping with complex medical, behavioral, and social needs.
• Gathers and reviews all information pertinent to each member’s case, including medical documentation covering medical, health, and rehabilitation concerns. Records the information and clinical impressions.
• Clinically certifies level of care determinations per the California Code of Regulations (CCR), Title 22 Sections 51334 and 51335, for each eligible applicant for whom there are reasonable indications MSSP services are required and justified.
• Continuously assesses and communicates each member’s status and progress through their participation in the program. If progress becomes static or regressive, determines cause and proactively makes appropriate adjustments in the care plan, assignment of providers, and/or services to promote better outcomes.
• Identifies and responds to member crisis situations by promptly prioritizing and implementing appropriate interventions.
• Initiates and maintains appropriate contact with each member’s family members, treating physicians, and other health care professionals to coordinate relevant information that will support the member’s functioning and coping in the community.
• Develops, implements, and updates each member’s individualized care plan through the interdisciplinary team (IDT) process in conjunction with the member and family, the supervising care manager, and the MSSP social worker across the full continuum of care.
• Collaborates with professionals across various disciplines involved in the member’s care, including those in community agencies, with an emphasis on interpreting and problem-solving the complex barriers to the member’s preferred care plan goals.
• Tracks each member’s quality of care and quality of life improvements, as measured against the established care plan goals.
• Advocates in the member’s best interest regarding the necessary benefit coverage, treatment alternatives, and access to care.
• Other projects and duties as assigned.
Possesses the Ability to:
• Evaluate the quality of necessary medical services and analyze the cost of care.
• Understand and abide by medical case management policies, procedures, and regulations.
• Establish and maintain effective working relationships with CalOptima leadership and staff, including those in other programs or agencies, and the public.
• Communicate clearly and concisely, both verbally and in writing; ability to prepare clear and comprehensive reports and materials.
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Experience & Education:
• Current, unrestricted Registered Nurse (RN) license to practice in the State of California required.
• 3 years of clinical experience working with the health needs of the population served, preferably 2 years of experience in public health with older adults, required.
• Valid driver’s license and vehicle, or other approved means of transportation, an acceptable driving record, and current auto insurance will be required for work away from the primary office 50% of the time or more.
• Bachelor’s degree in Nursing (BSN) preferred.
• Case Management Certification (CCM) preferred.
• Public Health Nurse (PHN) certification preferred.
• Experience in home health, hospice, or skilled nursing facility and Level of Care Certification process experience preferred.
• Bilingual in English and in one of CalOptima’s defined threshold language (Spanish, Vietnamese, Arabic, Farsi, Korean, Chinese) preferred.
• Guidelines and regulations relevant to care management and utilization management.
• Confidentiality and the legal and ethical issues pertaining to case management.
• Available community resources.
• Effective documentation practices and guidelines.
• Available medical treatments and resources.
• Principles and practices of health care, health care systems, and medical administration.
Department(s): Long-Term Services & Supports (LTSS)
Reports to: Manager, MSSP
FLSA status: Non-Exempt
Salary Grade: L – $37.02 – $57.64 ($77,000 – $119,900)
CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.
Job Location: Orange, California
To apply, visit https://apptrkr.com/3047287
Copyright ©2022 Jobelephant.com Inc. All rights reserved.