Health Net Care Manager II RN Oakland or Rancho Cordova, CA #31495 in Oakland, California
Care Manager II RN Oakland or Rancho Cordova, CA #31495Apply now »
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Date:Oct 17, 2016
Location:Oakland, CA, US, 94612
Company:Health Net, Inc.
Provides Case Management services to a specific clientele. Systematically identify and addresses fragmentation of care, and fill gaps in are using proactive initiatives. Assesses medical records for appropriateness, level of care provided and criteria determination. Identifies appropriate care for patients by evaluating high-risk cases, intensity and complexity of services, health care costs and non-compliance issues. Coordinates care between multiple providers. Develops care plans in coordination with providers, patients, families as appropriate and assess the effectiveness. Organizes and schedules training for all new Case Management employees. May conduct periodic quality assurance audits for accuracy and quality associated with training. May monitor and oversee workflow function in case management.
Essential Duties & Responsibilities
Coordination of Care
Contacts members of the medical team to discuss the patient’s course of progress and needs.
Arranges for all services required; coordinates services with the health care team to eliminate
duplication of service and conserve benefit dollars.
Contacts/visits family to check understanding of the patient’s diagnosis, prognosis and ability to provide caregiver support.
Checks home for safety factors and structural barriers, arranges for modifications
Reevaluates equipment, supplies, and services.
Identifies problems, anticipates complications and acts to avoid them; provides health instruction to the patient/family; refers the patient back to the physician or other health care team members as needed.
Identifies plateaus, improvements, regressions and depressions; counsels accordingly and recommends help.
Makes personal visits/contacts the physician to clarify diagnosis, prognosis, therapies, activities of daily living, etc.
Provides authorizations for any modalities of treatment recommended; investigates and suggests alternative treatments when appropriate.
Assists with getting information and forms for living wills, health care proxy, DNR order, etc.
Shares pertinent information about the patient with physician to achieve the best outcome.
Documents case summary based on information received and communicates with the beneficiary and involved providers.
Conducts personal visits to the patient’s home/hospital as needed.
Facilitates transfer of beneficiary throughout the different regions and within the region by collaborating with the military liaison to transition the beneficiary with minimal disruption of their health care services.
Coordinates the basic benefit and identifies and submits benefit modifications as appropriate or
submits a request to TMA for benefit exceptions/special programs.
Coordination of Financial Services
Assesses the benefit plan for coverage and limitations.
Negotiates for cost-effective rates for provider services, which includes:
Contacts multiple providers for a rate comparison of specialty items and identification of the most cost-effective approach.
Researches and identifies appropriate equipment that meets the beneficiary’s needs and pursues contracts with these providers.
Suggests medically appropriate alternatives to accomplish treatment plan goals more cost effectively.
Counsels the patient/ family on budgeting and notifying creditors.
Identifies financial distress and refers patient/family to appropriate community resources.
Helps patient /family sort and prioritize bills.
Acts as liaison among secondary insurance payers.
Aids with Behavioral/Motivational Activities
Explores patient’s feelings about his/her injury or illness; helps with associated trauma and frustration.
Monitors family’s feelings about the patient’s illness and observes the family’s ability to manage new emotional stress.
Offers information about patient’s condition.
Enlists qualified counselor to assist with problems arising from the injury or illness.
Bachelor Degree preferred
Must have and maintain current, valid and unrestricted Registered Nurse License.
Case Management Certified preferred
Five years clinical experience in a health care environment
Two years proven case management experience required
One year training or teaching experience preferred.
Managed care experience desirable. Internal candidates must have functioned in the capacity of a Case/Care Manager I.
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
Knowledge, Skills & Abilities
Exceptional written and oral communication skills; Demonstrated ability for assessment, evaluation and interpretation of medical information.
Skilled in the operation of the computer including proficiency in Microsoft Office Word, Excel and Access.
Excellent Interpersonal skills; and the ability to work effectively and independently.
Should have a high level of understanding of community resources, treatment options, and home health availability, funding options and special programs.
Group presentation design and facilitation skills.
The following section describes the general physical requirements for this position. Please note that ‘constant’ refers to more than 81% of time; ‘significant’ refers to 40-80%; and ‘moderate’ refers to 20-40% of the time.
Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
Required to have hearing ability to receive detailed information through oral communication.
Required to have speaking ability to express or exchange ideas.
Constant concentration may be required on various subjects by listening, reading and thinking clearly.
Interaction with others may be required. May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required. This may require face-to-face or telephone interactions.
Thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next.
Constant computer usage including typing and/or eye strain.
Constant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
Constant phone usage; headsets may be required.
Constant travel may be required between work sites and/or out of area.
Significant lifting may be required. May need to lift, carry and/or move equipment/supplies weighing up to 20 pounds, always using safe lifting techniques.
Constant sedentary work (desk bound or seated).
Constant reading is required via computer screen and/or bound printed materials.
Moderate walking/standing may be required. Walking and/or transporting supplies and equipment between buildings/parking lots and structures may be required.
DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified.