Health Net Care Manager RN Concurrent Review Sacramento, Rancho Cordova, Fresno, Oakland, CA #29749 in Rancho Cordova, California

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Date:Oct 17, 2016

Location:Rancho Cordova, CA, US, 95670

Company:Health Net, Inc.

Job Summary

The Care Manager II is responsible for providing care management services to beneficiaries with planned admissions to acute care hospitals, or to those transitioning from case management or disease management programs. Systematically identifies and addresses fragmented care for patients with acute, real-time needs and tailors interventions and services to fill gaps and produce optimal clinical outcomes. May also conduct Quality Assurance audits, monitor and oversee workflow, review and maintain policies and procedures, and perform system testing of modifications and enhancements.

Essential Duties & Responsibilities

Pre-Admission Counseling

  • Contacts patients with upcoming hospital admissions and discusses expectations.

  • Assesses patient’s condition to understand illness or injury and evaluate ability to follow treatment plan.

  • Advises patients of probable length of stay and helps anticipate and arrange for services at discharge.

Admission Care

  • Works with physicians and hospitals to enforce treatment plans and orders.

  • Ensures patient receives specialty care and tests as ordered.

  • Contacts medical team members to discuss patient’s course of progress and needs.

  • Arranges for and coordinates health care team services, avoiding duplication and conserving benefit dollars.

  • Evaluates need for and authorizes equipment, supplies, and services.

  • Identifies problems and instructs patient and family in proper care and refers patient back to physician or other health care team members.

  • Identifies plateaus, improvements, regressions and depressions, and counsels accordingly.

Coordination of Care

  • Conducts hospital visits.

  • Confers with physician to clarify diagnosis, prognosis, therapies, daily living activities, and to share information.

  • Authorizes recommended modalities of treatment. Investigates and suggests alternatives.

  • Documents case summary in Transitional Care Plan and shares appropriately with beneficiaries and providers.

  • Facilitates beneficiary transfers among regions and collaborates with military liaison to minimize disruption care or services.

  • Coordinates basic benefit. Identifies and submits modifications, requests for exceptions or special programs.

Coordination of Financial Services

  • Assesses patient’s benefit plan coverage and limitations.

  • Negotiates rates for provider services by contacting multiple providers and comparing specialty item costs, researching and identifying required equipment, and pursuing contracts.

  • Suggests medical alternatives that accomplish treatment plan goals.

Post Discharge Follow-up

  • Contacts patients within 48 hours of discharge to ensure sufficient support for full recovery.

  • Ensures proper receipt of equipment, home health and other services.

  • Assesses compliance with medications and follow-up appointments.

  • Assists patient in coordinating transportation and other basic needs, and in navigating the health care system.

Associate Training

  • Organizes, schedules and conducts program and skill training for Care Management associates.

  • Identifies and maintains ongoing training needs and designs training plans.

  • Develops care management policies and procedures, and facilitates and recommends process improvements.


Graduate of Nursing program, BSN Degree preferred

Certification/Licensure Required

  • Must have and maintain current RN License which is valid and unrestricted that meets requirement for the state in which you practice

Experience Required

  • Five years clinical experience in a health care environment; including Care Coordination, Nurse Advice/Triage, Case or Disease Management. Managed care experience preferred

  • Internal candidates must have functioned as a Case Manager I and received a satisfactory score on the Advancement Exam

Knowledge, Skills & Abilities

  • Exceptional written and oral communication skills

  • Demonstrated ability to assess, evaluate and interpret medical information

  • Skilled in computer operation with proficiency in Microsoft Office Word

  • Excellent Interpersonal skills and ability to work effectively and independently

  • High level of understanding of community resources, treatment options, home health availability, funding options and special programs

Working Conditions

  • 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.

  • Moderate 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.

Location: CA: Woodland Hills, Oakland or San Bernardino

Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.

Health Net and its subsidiaries are an Equal Opportunity/Affirmative Action Employer - Minorities/Females/Veterans/Disability