Outpatient Case Manager

Position information

• Job Title: Outpatient Case Manager
• FLSA Status: Non-Exempt
• Department: Clinical Services
• Reports To: Case Management Program Manager

Job summary

Under the supervision of the Case Management Program Manager, the Outpatient Case Manager is responsible for intake and providing case management services to members with chronic medical conditions and/or socioeconomic and mental health comorbidities.

The Outpatient Case Manager assists members in achieving optimal health outcomes and/or independence in self-managing their care. Familiarity with MCG and Medicare guidelines is required.

Essential job functions

Conducts health risk assessments, including but not limited to physical, functional, social, psychological, environmental, learning, and financial needs of the member.

Identifies problems, goals, and interventions to meet the member’s needs, including prioritized goals identified by the member and caregiver.

Creates individualized care plans with the member, caregiver, and member’s Primary Care Provider (PCP), including short- and long-term goals and interventions.

Provides appropriate interventions that demonstrate knowledge and sensitivity toward cultural diversity, religious and developmental considerations, health literacy, and educational backgrounds of the population served. Utilizes interpreter services as needed.

Evaluates the member’s progress toward goal achievement, including identification and evaluation of barriers to meeting the member’s needs. Reassesses for changes in goals and/or health status.

Conducts Interdisciplinary Care Team (ICT) meetings and communicates with the PCP and members of the interdisciplinary care team regarding the care plan and the member’s status.

Demonstrates knowledge and experience in managing and evaluating Health Risk Assessment (HRA) cases.

Acts as a member advocate and assists with problem-solving and addressing barriers to care.

Coordinates and refers members to appropriate community resources and facilitates access and communication when multiple services are involved.

Documents assessments and care plans in the Care Management System.

Adheres to payroll policies and properly utilizes the timekeeping system with minimal manual changes.

Maintains regular and consistent attendance.

Adheres to the Compliance Plan and HIPAA regulations.

Marginal job functions

Takes on special projects as needed.

Performs other duties as assigned.

Behavioral expectations

1. Continuous Learning

a. Attends staff meetings as required.

b. Attends appropriate training, seminars, and workshops as required.

2. Customer Focus

a. Maintains client/customer confidentiality and privacy in accordance with HIPAA regulations and IMAS’s Standards of Conduct.

b. Fosters appropriate communication and professional relationships with supervisors, co-workers, and other staff.

3. Quality / Process Improvement / Safety

a. Reports issues of security, health, and/or safety to the appropriate supervisor as soon as practicable.

b. Supports and demonstrates safety throughout all duties performed.

c. Follows established policies and procedures and understands and complies with all regulatory standards set forth by governing entities.

Position requirements

Education / experience

Minimum of 2 years of nursing experience in an acute care hospital setting.

Minimum of 1 year of managed care and utilization review experience.

Experience with CMS and MCG guidelines.

Experience with clinical review.

Clinical knowledge of chronic conditions, such as diabetes and congestive heart failure.

Strong written and verbal communication skills with patients, physicians, and other stakeholders.

Demonstrated ability to assess and respond to patient and family needs in a timely manner.

General knowledge of case management practices, including familiarity with relevant products and services.

Basic computer skills, including working knowledge of the Microsoft Office Suite (Excel, Outlook, PowerPoint, and Word).

Experience establishing professional and collaborative relationships with patients, physicians, and insurance providers.

Experience in managed care.

Associate degree or higher in nursing.

Skills / knowledge / ability

Knowledge of Medicare, Medicaid, and Managed Care Organization (MCO) guidelines and requirements.

Willingness and ability to read, write, speak, and understand English and possess the communication skills necessary to provide accurate information to members and staff.

Willingness and ability to follow written and verbal directions in English.

Willingness and ability to maintain an appropriate level of confidentiality and privacy.

Willingness and ability to interact professionally with all customers, members, and co-workers, individually and as part of a team.

Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to changing priorities.

Willingness and ability to make appropriate judgments and decisions and apply effective problem-solving skills in a timely manner and within the context of the situation at hand.

Ability to effectively prioritize items/tasks as required.

Willingness and ability to take initiative and be a self-starter.

Willingness and ability to understand and comply with federal, state, and local regulations.

Licensure / certificate / training

Active, current, unrestricted California LVN or RN license from an accredited school of nursing.

This is our weekend Nurse Reviewer who must be available to work Saturday & Sunday PST hours.