Job Description

JOB TITLE:  Case Manager RN/LVN

COMPANY:  My Choice Quality Care Network

REPORTS TO: Director of Clinical Strategy

STATUS:  Exempt / FULL TIME

WORK COMP CLASS: 8810

OUTSIDE TRAVEL 25% (Candidate must live in San Diego or the surrounding area)

WORK CONDITIONS:  Remote / Home Office

WORK SCHEDULE: 7-7/M-F

This job description is intended to be a general statement about this job and is not to be considered a detailed assignment. It may be modified at any time, with or without advance notice, to meet the needs of the organization.

JOB SUMMARY

My Choice Quality Care Network (MCQCN) is a newly formed FLEX Model Accountable Care Organization (ACO), a subsidiary of Integrated Health Partners of Southern California, a high value Clinically Integrated Network (CIN) managing over 350,000 Medi-Cal (Medicaid) lives. The ACO was created to bring the value of health centers to the aging population focusing on access to high value quality care and coordinated social care management strategies. The ACO is developing the clinical care and social model to support the Medicare beneficiary clinical, behavioral, social, and support needs of which the clinical care team is critical. This position, under the supervision of the Director of Clinical Strategy, is responsible for facilitating and coordinating care management services within the ACO population. The role involves care planning, coordination, and facilitation activities that promote high-quality and cost-effective access to clinical, behavioral, and social care.

The position will assess patient needs and develop actionable care plans to help overcome clinical and social barriers to receiving high-value care. Additionally, the position will work closely with patients and health centers to ensure that care plans are implemented effectively, ensuring patients receive the right care at the right time in the right setting, leading to positive outcomes and experiences.

ESSENTIAL JOB FUNCTIONS

Case Management

1. Patient/Caregiver Experience

• Develop personalized care plans for each patient outlining a whole-person approach to address the services and resources needed to improve the patient’s health.
• Ensure patient engagement and communication of active care plans and ensure communication of non-compliance to health center clinicians for updates needed to the care journey.
• Develop and implement strategies to improve patient satisfaction.
• Facilitate communication between patients, caregivers, and healthcare providers to ensure a positive experience.
• Address patient concerns and complaints promptly to enhance the overall patient experience.
• Educate patients and caregivers about available clinical and non-clinical resources and support services.

2. Care Coordination/Patient Safety

• Monitor hospital admissions and readmissions to identify patterns and develop strategies to reduce avoidable admissions.
• Utilize Arcadia and health center EMR to track patient information and ensure seamless care transitions.
• Coordinate care among various healthcare providers to ensure continuity and safety.
• Implement and monitor patient safety protocols to minimize risks and improve outcomes.
• Conduct regular reviews of patient care plans to ensure they are up-to-date and effective.

3. Preventive Health

• Promote and facilitate wellness screenings, such as body mass index (BMI) assessments and disease screenings (e.g., breast cancer).
• Educate patients about the importance of preventive health measures and encourage participation in wellness programs.
• Track and report on preventive health metrics to identify areas for improvement.
• Provide resources and support to patients to help them maintain a healthy lifestyle.
• Review payer and Arcadia quality performance reports to identify the quality metrics that are performing below performance thresholds and develop and implement clinical action plans to address gaps in care, access, and/or quality outcome issues.

4. Clinical Care for At-Risk Populations

• Manage the care of patients with chronic conditions, such as diabetes and hypertension, to ensure they receive appropriate treatment.
• Develop personalized care plans for at-risk patients to address their specific health needs.
• Monitor and evaluate the effectiveness of care plans and adjust as needed.
• Coordinate with specialists and other healthcare providers to ensure comprehensive care for at-risk patients.
• Educate patients about managing their health conditions and provide support to help them adhere to their treatment plans.
• Coordinate care with health centers to ensure there is a cohesive plan to help patients achieve optimal health outcomes.

5. Coding & Documentation Integrity

• Provide clinical guidance on HCC coding or documentation audits performed by the Coding & Documentation Integrity Team.
• Utilize coding chart review summaries to work with health center clinicians or specialists to ensure proper documentation of patient conditions to support clinical, social, or behavioral health service needs.

Other

• Develop team members and create tools to ensure strong teams and processes are in place for success. Meet annual goals outlined by leadership that align with the network strategic plan.
• Establish and maintain collaborative working relationships with community resources.
• Actively participate in staff meetings and training.
• Perform other duties as assigned.

QUALIFICATIONS

Education and Experience

• RN, or LVN license required.
• CCMC, or equivalent, preferred certification.
• Must have 2-3 years clinical experience: 3+ years preferred.
• Working knowledge of regional health disparities and social determinants of health.
• Working knowledge of Medicare and Medicare Advantage payer populations preferred.
• Must have strong interpersonal skills to work effectively internally and externally and across all levels in an organization.
• Working knowledge of relevant computer systems and software.
• Must have excellent written and verbal communication skills.
• Must possess valid driver’s license, insurance, and own transportation for use in work, and be flexible with working some evenings and weekends within a 40-hour workweek.
• Must reside in San Diego

Other Required Skills/Abilities

Physical Requirements

• Ability to sit or stand for long periods of time
• Ability to reach, bend and stoop
• Physical ability to lift and carry up to 20 lbs.
• Office setting.
• Frequent daily use of computer, telephone, copier and FAX machines.
• Regular periods of high stress and long days.
• Must be responsive to multiple deadlines.

HIPAA/COMPLIANCE

• Maintain privacy of all patients, employee and volunteer information and access such information only on as need to know basis for business purposes.
• Comply with all regulations regarding corporate integrity and security obligations. Report unethical, fraudulent, or unlawful behavior or activity.
• Upon hire and annually attend HCP’s HIPAA training and sign HCP’s Confidentiality & Non-Disclosure Agreement and HIPAA Privacy Acknowledgment
• Upon hire and annually read and acknowledge understanding of HCP’s HIPAA Security Policies and Procedures
• Adhere to HCP’s HIPAA Security Policies and Procedures and report all security incidents to HCP’s Privacy & Security Officer

“ We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law”.

*The pay range for California residents for this position is $84,000-$106,000, however, the actual base pay offered may vary depending on skills, experience, job- related knowledge and location. To promote fairness and pay equity, we typically offer new hires salaries near, at, or below midpoint of our posted ranges*

Job Type: Full-time

Pay: $84,000.00 - $106,000.00 per year

Benefits:

• 403(b)
• 403(b) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Employee discount
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Mileage reimbursement
• Paid sick time
• Paid time off
• Parental leave
• Retirement plan
• Vision insurance

Schedule:

• Option to work 9/80 schedule (9 hour day with every other Friday off)
• Monday to Friday

Experience:

• Clinical: 3 years (Preferred)
• Medicare Knowledge: 3 years (Preferred)
• Accountable Care Org: 2 years (Required)

License/Certification:

• RN License (Preferred)
• LVN (Preferred)

Location:

• San Diego, CA (Required)

Work Location: Remote

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