Outpatient Case Manager

Imperial Health Plan of California, Inc.; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

Imperial Health Plan of California, Inc. is seeking an Outpatient Case Manager to provide case management services for members with chronic medical conditions. The role involves conducting health risk assessments and developing individualized care plans.

Qualified candidates will have a minimum of 2 years of nursing experience and demonstrate excellent communication and problem-solving skills. Familiarity with CMS and MCG guidelines is essential.

Qualifications

• 2+ years of nursing experience in an acute care hospital setting.
• 1+ years of managed care and utilization review experience.
• Experience in CMS and MCG.
• Clinical knowledge of chronic conditions such as diabetes and congestive heart failure.

Responsibilities

• Conduct health risk assessments to identify members' needs.
• Create individualized care plans with members and caregivers.
• Evaluate members' progress toward goal achievement.

Skills

Health risk assessments

Case management practices

Communication skills

Problem-solving

Cultural sensitivity

Education

2+ years of nursing experience in an acute care hospital setting

1+ years of managed care and utilization review experience

Tools

CMS

MCG

Job description

JOB TITLE: Outpatient Case Manager FLSA STATUS: Non-Exempt

DEPARTMENT: Clinical Services

REPORTS TO: Case Management Program Manager

JOB SUMMARY: Under the supervision of the Case Management Program Manager, the Outpatient Case Manager is responsible for intake and providing case management services for members with chronic medical conditions, and/or socioeconomic and mental health co-morbidities. The Outpatient Case Manager is to assist these members to achieve optimal health and/or independence in self-managing their care. Familiar with MCG and Medicare Guidelines.

Essential Job Functions

• Conducts health risk assessments, including, but not limited to, physical, functional, social, psychological, environmental, learning, and financial needs of the member.
• Identify problems, goals, and interventions to meet members’ needs, including prioritized goals that are preferred by member and caregivers.
• Create an individualized care plan with the member, caregiver, and the member’s PCP to include short‑/long‑term goals and interventions.
• Provide appropriate interventions that demonstrate knowledge and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Use interpreter services as needed.
• Evaluate member’s progress toward goal achievement, including identification and evaluation of barriers to meeting member’s needs. Reassess for changes in goals and/or health status.
• Conduct an ICT meeting to communicate with PCP and members of the interdisciplinary care team about the care plan and the member’s status.
• Knowledge and experience managing and evaluating HRA cases.
• Act as a member advocate and assist with problem‑solving and addressing any barriers to care needs.
• Coordinate and refer to appropriate community resources; facilitate access and communication when multiple services are involved.

Education / Experience

Position requires the following education and experience:

• 2+ years of nursing experience in an acute care hospital setting.
• 1+ years of managed care and utilization review experience.
• Experience in CMS and MCG.
• Experience with clinical review.
• Clinical knowledge of chronic conditions such as diabetes and congestive heart failure.
• Strong written and verbal communication skills with patients, physicians, and other stakeholders.
• Demonstrated ability to assess and respond to patient and family needs in a timely manner.
• General knowledge of case management practices, including familiarity with relevant products and services.