Medical Case Manager, CalAIM (RN)

CalOptima; Orange (CA); Hybride; USD 91 000 - 145 000; Plein temps

Avantages offerts par ce poste

Generous PTO

Wellness programs

Tuition reimbursement

Flexible scheduling

Career development opportunities

Résumé du poste

CalOptima is seeking a Medical Case Manager (RN) for the CalAIM program to review authorizations, coordinate referrals, and collaborate with health networks. The role supports remote and part-time in-office attendance with primary responsibilities in California.

The ideal candidate holds an RN license, ADN or BSN, and experience in managed care or authorization reviews. Bilingual skills are a plus, and the team emphasizes high-quality service and equity in care.

Qualifications

• Associate degree in nursing (ADN) plus 3 years nursing experience required; may count education equivalently.
• RN license in the state of California required; BSN is a plus.
• Bilingual in English and one threshold language (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese) is a plus.

Responsabilités

• Review and process authorization and notification of CalAIM services.
• Authorize referral requests using CalAIM criteria and policies.
• Coordinate member care with health networks and providers.
• Document data entries accurately in UM/CM systems.
• Interact with provider callers and respond to inquiries to support access to care.

Connaissances

RN license required

Nursing experience

Managed care experience

Authorization review experience

Bilingual English + Spanish

Formation

ADN + 3 years nursing experience

BSN preferred

RN license in California

Outils

Microsoft Office

CalOptima Health Connect

Description du poste

Medical Case Manager, CalAIM (RN)

CalOptima

Join Us in this Amazing Opportunity

The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

More About the Opportunity

We are hoping you will join us as a Medical Case Manager (RN) and help shape the future of healthcare where you'll be an integral part of our Long Term Care team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework.

– If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

The Medical Case Manager for CalAIM is responsible for reviewing and processing requests for authorization and notification of CalAIM services. You'll be responsible for CalAIM authorization and referral related processes which include on-line responsibilities as well as selected off-line tasks. Additionally, you'll utilize CalOptima Health's CalAIM criteria, policies and procedures to authorize referral requests. Finally, you'll directly interact with provider callers and serve as a resource for their needs.Together, we are building a stronger, more equitable health system.

Your Contributions To the Team:

• 95% - Program Support
• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Reviews authorization requests for CalAIM services for medical appropriateness utilizing medical criteria and/or established CalOptima Health policies and procedures.
• Verifies and processes CalAIM referrals via CalOptima Health Connect, telephone or fax while using established clinical protocols to determine medical necessity.
• Coordinates member care with health networks, CalOptima Health team members and CalAIM providers.
• Completes required documentation accurately and appropriately for data entry into the utilization management or care management system at the time of the telephone call or fax making sure to include any authorization updates.
• Determines the appropriate action regarding the service being requested for approval, modification or denial, and refers to the Medical Director for review when necessary.
• Initiates contact with the patient, family and CalAIM providers as needed to obtain additional information.
• Meets productivity and quality of work standards on an ongoing basis.
• 5% - Other
• Completes other projects and duties as assigned.

Do You Have What the Role Requires?

• Associate degree in nursing (ADN) PLUS 3 years of nursing experience with 1 year as a Clinical Nurse Reviewer required; an equal combination of education sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

You'll Stand Out More If You Possess the Following:

• Bachelor of Science in Nursing (BSN).
• Managed care experience.
• Authorization review experience.
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Russian, Spanish, Vietnamese).

What the Regulatory Agencies Need You to Possess?

• Current unrestricted Registered Nurse (RN) license to practice in the state of California required.

Your Knowledge & Abilities to Bring to this Role:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Your Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds.

Ways We Are Here For You

• You’ll enjoy competitive compensation for this role.
• Our current hiring range is: Pay Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615).
• The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.
• This position is approved for Full Telework (If the position is Telework, it is eligible in California only).
• A https://www.caloptima.org/en/careers#benefits
• CalPERS pension program and additional retirement packages.
• Additional benefits and perks including:
• A generous PTO program
• A quality work life balance
• Various wellness programs
• Tuition Reimbursement
• Professional development opportunities
• Career development opportunities
• Flexible scheduling
• And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.

Our Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

Why Join Us?

We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.

Our Commitment to You

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at [phone] if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.