Case Manager

Astiva Health, Inc; California; Presencial; USD 70.000 - 95.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

401k

Health Insurance

Vision Insurance

Life Insurance

Paid Time Off

Free catered lunches

Descripción de la vacante

Astiva Health, Inc., located in Orange, CA, is seeking an Ambulatory Case Manager to join an interdisciplinary team and ensure optimal utilization management, care coordination, and clinical documentation across the continuum of care. The ACM reports to the CM Manager and advances patient care plans within CMS guidelines.

The role emphasizes patient advocacy, documentation integrity, and collaboration with internal and external partners to achieve quality outcomes and member satisfaction.

Formación

• Active, unrestricted California clinical license required (LVN, RN, LCSW, LMFT, or LPCC).
• 1–3+ years of case management experience preferred.
• Experience with Medicare Advantage, SNPs, or managed care preferred.

Responsabilidades

• Conduct initial Health Risk Assessments (HRAs) for newly enrolled members within CMS-required timeframes.
• Perform reassessments following significant changes in condition or care setting.
• Coordinate with CMS Model of Care requirements to complete deliverables.
• Maintain timely, accurate documentation in the care management platform.
• Adhere to HIPAA and privacy requirements and collaborate with internal teams.

Conocimientos

Bilingual capability

Healthcare coordination

Documentation

Educación

California clinical license (LVN/RN/LCSW/LMFT/LPCC)

Herramientas

Microsoft Excel

PowerPoint

Outlook

Teams

Descripción del empleo

Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.

SUMMARY: Astiva Health Inc is looking for a highly energetic and collaborative ambulatory case manager. This role will report to the Case Management (CM) Manager. The primary objective of the Ambulatory Case Manager (ACM) is to work within an interdisciplinary team to facilitate the patient plan of care throughout the continuum of care by ensuring appropriate utilization management, care coordination, resource utilization, and clinical documentation in accordance with the Model of Care and CMS regulations. The ACM will function within the Astiva Case Management department, which includes accountability for assessing, planning, implementing, evaluating, and communicating the patient care plan progression. The ACM utilizes the principles of mutual respect, member/family advocacy and coordinates within the team of internal partners and outside agencies to facilitate best practices, achieving quality clinical, financial, and member satisfaction outcomes.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.

• Conduct initial Health Risk Assessments (HRAs) for newly enrolled C-SNP members within CMS-required timeframes and annual reassessments thereafter.
• Perform reassessments including but not limited to acuity following any significant change in condition, hospitalization, ED visit, change in care setting, or member request.
• Use standardized, validated assessment tools to evaluate medical, functional, cognitive, behavioral, psychosocial, nutritional, pharmacologic, caregiver, environmental, and advance care planning needs.
• Coordinate with members and providers outlined in the CMS Model of Care requirements to complete required deliverables.
• Follow internal protocols related to Transitions of Care and coordinate care as needed
• Educate members and caregivers on warning signs, when to seek care, and identify appropriate facility to meet needs
• Flag members with gaps in care, including preventive screenings, chronic condition management metrics, and medication adherence issues.
• Apply motivational interviewing, health coaching, and behavior change techniques to support member activation and self-efficacy.
• Provide caregiver education, support, and connection to respite and caregiver resources.
• Meet individual productivity, engagement rate, and case-closure targets as defined by the program.
• Maintain timely, accurate, and complete documentation in the care management platform consistent with CMS, NCQA, DHCS, DMHC, organizational standards, and outlined in the CMS Model of Care.
• Adhere to HIPAA, confidentiality, and privacy requirements in all member interactions and documentation.
• Comply with mandated reporting requirements for suspected abuse, neglect, or self-harm.
• Practice within the scope of state licensure at all times.
• Collaborate with utilization management, quality, pharmacy, member services, and provider relations teams to support integrated member care.
• Maintain clinical knowledge through continuing education, certification maintenance, and awareness of evolving Medicare Advantage and SNP regulations.
• Other duties as assigned.

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE:

• Active, unrestricted California clinical license required (LVN, RN, LCSW, LMFT, or LPCC).
• 1-3 or more years of case management experience required.
• Experience with Medicare Advantage, Special Needs Plans (C-SNP, D-SNP, or I-SNP), or managed care preferred.
• Experience working with adult and geriatric populations with chronic and complex conditions preferred.
• Experience with Microsoft Excel, PowerPoint, Outlook, and Teams preferred.
• Bilingual capability (e.g., Spanish, Mandarin, Cantonese, Vietnamese, Korean, Tagalog) preferred

BENEFITS:

• 401k
• Health Insurance
• Vision Insurance
• Life Insurance
• Paid Time Off
• Free catered lunches

LANGUAGE: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups and customers or employees of the organization.

MATHEMATICS: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.

EEO/AFFIRMATIVE ACTION STATEMENT: It is the policy of Astiva Health to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law. This policy relates to all phases of employment, including but not limited to recruiting, employment, placement, promotion, transfer, demotion, reduction of workforce and terminaly, rates of pay or other forms of compensation, selection for training, the use of all facilities, and participation in all company sponsored employee activities. Provisions in applicable laws providing for bona fide occupational qualifications, business necessity or age limitations will be adhered to by the organization where appropriate. Please refer to Standard Operating Procedure 100 for more information about the organization’s Affinitive Action/EEO statement.

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to sit and complete work while on a computer. The employee occasionally is required to stand, walk, use hands to finger, handle or feel, reach with hands and arms, stoop, kneel, crouch or crawl, climb or balance, talk and hear.

While performing the duties of this job, the employee is occasionally required to lift or exert force up to 10 pounds.

WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.