Medical Case Manager, CalAIM; RN

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

We are hoping you will join us as a Medical Case Manager (RN)and help shape the future of healthcare where you’ll be an integral part of our Long Term Care
team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be
Full Telework
.

• If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

The Medical Case Manager for CalAIM is responsible for reviewing and processing requests for authorization and notification of CalAIM services. You'll be responsible for CalAIM authorization and referral related processes which include on-line responsibilities as well as selected off-line tasks. Additionally, you'll utilize Cal Optima Health’s CalAIM criteria, policies and procedures to authorize referral requests. Finally, you'll directly interact with provider callers and serve as a resource for their needs.

Together, we are building a stronger, more equitable health system.

• 95% - Program Support
  • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
  • Reviews authorization requests for CalAIM services for medical appropriateness utilizing medical criteria and/or established Cal Optima Health policies and procedures.
  • Verifies and processes CalAIM referrals via Cal Optima Health Connect, telephone or fax while using established clinical protocols to determine medical necessity.
  • Coordinates member care with health networks, Cal Optima Health team members and CalAIM providers.
  • Completes required documentation accurately and appropriately for data entry into the utilization management or care management system at the time of the telephone call or fax making sure to include any authorization updates.
  • Determines the appropriate action regarding the service being requested for approval, modification or denial, and refers to the Medical Director for review when necessary.
  • Initiates contact with the patient, family and CalAIM providers as needed to obtain additional information.
  • Meets productivity and quality of work standards on an ongoing basis.
• 5% - Other
  • Completes other projects and duties as assigned.

• Associate degree in nursing (ADN) PLUS 3 years of nursing experience with 1 year as a Clinical Nurse Reviewer required; an equivalent combination of education sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

• Bachelor of Science in Nursing (BSN).
• Managed care experience.
• Authorization review experience.
• Bilingual in English and in one of Cal Optima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).

• Current unrestricted Registered Nurse (RN) license to practice in the state of California required.

• Develop rapport and establish and maintain effective working relationships with Cal Optima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external…