Complex Case Manager (CCM) is responsible for coordinating resources, researching appropriate cost-effective alternative/ options for the catastrophic, chronically ill, identified high-risk members on a case by case basis to achieve realistic healthcare outcomes. The primary goal of the CCM is to assist with optimizing member care across the healthcare continuum to decrease healthcare utilization and prevent avoidable emergency room visits and hospital admissions. The CCM is responsible for collaborating closely with the member and multi-disciplinary teams regarding the member condition(s) and developing a care plan that fits the needs of the member. The CCM provides appropriate member self management education on their specific healthcare needs. The CCM will complete both telephonic and in person communication with the member based on the member’s level of acuity.
Essential Functions and Key Responsibilities (in descending order of importance):
% of Time
Communicate and collaborate with member and providers on care planning and healthcare needs to ensure person centered care planning and execution of care planning
Care plan and member healthcare assessment documentation based on NCQA Standards and Regulatory requirements
Communicate and collaborate with multidisciplinary team regarding member care plan and healthcare needs
Attend and present CCM cases at interdisciplinary care team (ICT) rounds
Complete in person visits with members as needed
Experience: Minimum of two years experience in Case Management in a Managed Care environment and minimum three experiences in an acute care setting; Health Plan experience preferred
Education: Registered Nurse with a Bachelor’s Degree; Associate’s Degree will be considered with appropriate additional years of experience
License/Certification/Special Training: Active CA RN License, CA Driver’s License with ability to provide own transportation within San Diego or Los Angeles County, Certification in Case Management (CCM) preferred with ability to complete certification within 1 year of employment.
Skills/Abilities: Knowledge of Medicare, Medical and Cal-Medi Connect program regulations. Knowledge of NCQA Standards. Ability to navigate through complex healthcare systems in a fast pace environment. Ability to create member specific care plans based on their healthcare goals.
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork – Activity level: Sedentary, frequency most of work day.
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