RN Case Manager

RN Case Manager

Salary Range : $111,168 - $172,310

The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status : Exempt

Department : Health Services

Reports To : Health Services Management

Employee Unit : Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521

GENERAL DESCRIPTION OF POSITION

The RN Case Manager is responsible for providing on-going case management services for Santa Clara Family Health Plan (SCFHP) members. As a SCFHP member advocate, the RN Case Manager facilitates communication and coordination among all participants of the care team to ensure member identified goals and needed services are provided to promote quality cost-effective outcomes. Through the development and implementation of member individualized care plans, the RN Case Manager provides medical and psychosocial case management support to help coordinate resources and services for individuals across the healthcare and social services continuum, and facilitate the use of available healthcare benefits in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

• Conduct, review and document comprehensive clinical and / or psychosocial assessments and on-going follow-up interventions to measure progress towards meeting goals as they relate to a member's physical, psychosocial, environmental, safety, developmental, cultural and linguistic needs.
• Maintain case files by assuring that they are documented in accordance with SCFHP policies and procedures, state and federal requirements and organized in a manner that adheres to standards for audit requirements.
• Facilitate involvement of the member and / or family / responsible party for development and implementation of a member specific care plan which includes individualized prioritized goals.
• Coordinate member's care with PCP, Specialists, Behavioral Health and Long Term Services and Supports providers to assist member to achieve or maintain a level of functional independence which allows them to remain at home or in the community.
• Facilitate and coordinate communication with member's interdisciplinary care team including SCFHP internal staff, as well as the member's physicians, specialists, public services, community agencies and vendors to ensure care plan development and coordination of benefits and services.
• Facilitate successful transition of care for members who move between care settings by coordinating services for medical appointments, pharmacy assistance and by facilitating utilization review.
• If assigned to MLTSS, support the transition of long-term care members residing in nursing facilities to a lower level of care, or community setting in partnership with MLTSS providers and programs.
• If assigned to Community Based Adult Services (CBAS) :

Conduct face-to-face, on-site eligibility determinations for CBAS services with members using the standardized California Department of Health Services approved tool - CBAS Eligibility Determination Tool (CEDT) & Patient Health Record Quick Guide;

REQUIREMENTS - Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and / or ability required or desired.

WORKING CONDITIONS

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation :

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.

EOE

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