Case Management Assistant, TCS; PHM- Bakersfield

Description Employment Details

Location
:
Bakersfield, CA. (Onsite)

Classification
:
Full-Time

Schedule
:

Monday-Friday 8:00 AM – 5:00 PM

Benefits
:

• Medical
• Dental
• Vision
• Paid Time Off (PTO)
• Floating Holiday
• Simple IRA Plan with a 3% Employer Contribution
• Employer Paid Life Insurance
• Employee Assistance Program

Compensation
:
The initial pay range for this position upon commencement of employment is projected to fall between $21.31 and $26.63 per hour. Compensation may be adjusted based on individual knowledge, skills, and experience. The organization offers competitive packages to attract and retain top talent.

Position Summary
:

The Case Management Assistant (CMA) – Transitional Care Services provides support to the Population Health Management (PHM) team, focusing on members undergoing transitions of care. The CMA assists in enhanced care coordination activities for members moving between settings such as emergency departments, inpatient admissions, and post‑acute facilities. Responsibilities include coordinating services, scheduling timely follow‑up appointments, gathering clinical information, and conducting outreach to confirm that needs are being met.

Proactive contact with members during transitions, prior to discharge, helps coordinate the transition process and post‑discharge follow‑up, with the goal of reducing readmissions and avoidable ER visits. The role may also be assigned to a designated clinic site, with duties performed through telephonic, virtual, and in‑person engagement with members, providers, and care teams.

• Work collaboratively with the PHM team, including nurse case managers, social workers, and TOC clinic staff, to support members in need of transitional care services.
• Contact members during care transitions, especially prior to discharge, to help coordinate the transition process and post‑discharge follow‑up, with the goal of reducing readmissions and avoidable ER visits.
• Gather clinical information and assist with coordinating post‑discharge services, including home health care, prescriptions, durable medical equipment (DME), and transportation, ensuring referrals are received and confirming members understand follow‑up needs.
• Schedule primary care provider (PCP) post‑discharge visits and/or Transitions of Care (TOC) Clinic appointments in a timely manner.
• Proactively coordinate with referral sources and internal partners to support seamless member transitions between care settings.
• Support PHM members of all risk levels, from low to complex, who are experiencing transitions of care (e.g., ED, inpatient, post‑acute, and other settings).
• Contact members at regular intervals per care plan needs and acuity level, or as directed by the member’s Primary Case Manager.
• Initiate and/or complete applicable assessments, such as Health Risk Assessments (HRA), initial assessments, and/or Transitional Care Services (TCS) assessments, and consistently document activities and encounters in the case management system.
• Support case managers with follow‑up, communication with agencies, and preparation/distribution of documents or reports.
• Report and elevate member concerns, variances, or changes in condition to the appropriate care team members, including Nurse Case Managers and Social Services staff, to ensure timely intervention and coordinated follow‑up.
• Assist members with appointment scheduling, transportation, referral coordination, and other care coordination needs.
• Gather clinical information from outside sources such as SNFs, PCPs, specialists, hospitals, and applicable electronic health record systems, and upload it in the case management (CM) system.
• Ensure relevant TOC Clinic records are shared with the member’s PCP to help facilitate continuity of care.
• Verify member eligibility, demographics, benefits, and case management program eligibility.
• Ensure closed‑loop referrals to community supports, housing, and social service agencies, with follow‑up to confirm services were delivered, including services authorized by the organization.
• Participate in Interdisciplinary Care Team (ICT) meetings by gathering and presenting information and communicating member needs…