This position will be responsible for the daily operation of case management activities, and implementation of new programs and regulations. The incumbent will provide guidance to staff or directly handle complex case management referrals. Serves as a resource for CalOptima providers, health networks and community partners, and may attend meetings for the Manager.

Position Responsibilities:

  • Mentors, trains, and manages team of case managers and non-licensed staff.
  • Oversees the process, management and tracking of case management referrals.
  • Reviews health network Model of Care files and provides feedback to ensure compliance with regulatory guidelines.
  • Provides guidance or directly handles complex case management requests from members, providers or staff.
  • Assists with the development and oversight of case management programs, work plans and reports.
  • Collaborates with other supervisors and managers in the department to improve processes and work flow.
  • Reviews and revises policies and procedures to ensure NCQA, CMS and DHCS regulatory compliance.
  • Creates, documents and updates desktop procedures.
  • Participates in health network oversight activities, as required.
  • Assists with assessment activities and other process improvement strategies to enhance the effectiveness of the case management department.
  • Maintains knowledge of current regulatory requirements and industry trends.
  • Serves as a resource for CalOptima providers, health networks and community partners.
  • Participates in internal and external committees, coalitions and events such as health fairs, as appropriate.
  • Other projects and duties as assigned.
  • Communicate effectively, both verbally and in writing, including presentations.
  • Establish and maintain effective interpersonal relationships with staff at all levels, providers, other program or agency representatives, and the public.
  • Build team engagement.
  • Systematically evaluate work and apply skills to continuously improve processes.
  • Provide excellent customer service.
  • Initiate and follow through on projects with minimal supervision.
  • Work well as part of a team to manage/lead multiple projects simultaneously.
  • Think critically to solve problems effectively.
  • Effectively utilize computer and appropriate software (Microsoft Office: Word, Outlook, Power Point, Excel and Visio).

Experience & Education:

  • Current unrestricted California RN license required.
  • Bachelor?s degree in Nursing preferred.
  • Minimum of 3 years case management experience required, preferably in a managed care setting.
  • Active Certified Case Manager (CCM) certification preferred.
  • Previous supervisory experience strongly desired.

Knowledge of:

  • Disease process and clinical practice guidelines.
  • Case Management program planning and evaluation.
  • Appropriate techniques, practices and cultural sensitivities to serve diverse groups.

Grade:? N

Associated topics: business development, case management, development, development manager, liaison, manage, plan, project, project development, project management

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