RN Complex Case Manager in Pasadena, California at Imperial Management Administrators Services Inc

JOB DESCRIPTION

JOB TITLE: Complex Case Manager- Mental Health

FLSA STATUS: Non-Exempt

DEPARTMENT: Utilization Management

REPORTS TO: Dir of Clinical Services

JOB SUMMARY: Responsible for health care management and coordination within the scope of licensure for members with complex and chronic care needs within the Behavioral Health / Mental Health population. by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize mental health care across the care continuum. The Complex Case Manager will connect with the members on the phone to implement and tailor care plans according to the member’s mental health needs. Along with other members of the health team, conduct comprehensive assessments that include the medical, behavioral, pharmaceutical and social needs of the patient, identify gaps in care and barriers to attaining improved health. Based on this assessment, and in conjunction with the member, the member’s physician and other members of the health team, create and implement a care plan that will address the identified mental health needs, remove the barriers and improve the health of the member.

ESSENTIAL JOB FUNCTIONS:

1. Coordinate care by serving as a resource for the member with complex health needs, their family and their physician.

2. Conduct health risk assessments with members via phone to address the health and wellness needs of members.

3. Develop individualized care plans on members specific needs that account for physical, mental health and psychosocial needs and other constraints.

4. Measure, improve and maintain quality outcomes (clinical, financial, and functional) for individual patients and the population served.

5. Ensure access to appropriate mental health care for members with urgent or immediate needs facilitating referrals/authorizations within the benefit structure as appropriate.

6. Assesses the member's current health status, resource utilization, past and present treatment plan and services; prognosis, short and long term goals, treatment and provider options.

7. Monitors and evaluates effectiveness of the care management plan and modifies as necessary.

8. Conducts and participates in IDT meetings.

9. Interfaces with Psychiatrist, Primary Care Physicians, Nurse Practitioners and specialists on the development of care management treatment plans.

10. Provide education and self-management support based on the patient’s unique learning style.

11. Assists in problem solving with providers, claims or service issues.

12. Measures the effectiveness of interventions to determine case management outcomes.

13. Works closely with delegated or contracted providers, groups or entities (as assigned) to assure effective and efficient care coordination.

14. Maintains confidentiality of all PHI in compliance with state and federal law and Alignment Healthcare Policy.

15. Adheres to payroll policies and properly uses timekeeping system with minimal manual changes.

16. Maintains regular and consistent attendance.

17. Adheres to Compliance Plan and HIPAA regulations.

MARGINAL JOB FUNCTIONS:

1. Takes on special projects as needed.

2. Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS:

1. Continuous Learning:

a. Attends staff meetings as required.

b. Attends appropriate training, seminars and workshops as required

2. Customer Focus:

a. Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations

and IMAS’s Standards of Conduct.

b. Fosters appropriate communication and relations with Supervisor, co-workers and other staff.

3. Quality/Process Improvement/Safety

a. Reports issues of security, health and/or safety to appropriate supervisor as soon as practicable.

b. Supports and demonstrates safety throughout all duties performed.

c. Follows established policies and procedures and understands and complies with all regulators

standards set forth by governing entities.

POSITION REQUIREMENTS:

EDUCATION/EXPERIENCE:

• 2+ years of nursing experience in a mental health / psychiatric setting

• 1+ years of managed care and utilization review experience

• Experience with clinical review

SKILLS/KNOWLEDGE/ABILITY:

• Spanish speaking or other second language a plus

• Willingness and ability to read, write, speak, understand English and have the communications

skills necessary to provide accurate information to members and staff.

• Willingness and ability to follow written and verbal direction in English.

• Willingness and ability to maintain appropriate level of confidentiality and privacy.

• Willingness and ability to interact professionally with all customers, members, and co-workers,

individually and as part of a team.

• Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to

changing priorities.

• Willingness and ability to make appropriate judgments, decisions and problem solving in a timely

manner and within the context of the situation at hand.

• Ability to effectively prioritize items/tasks as required.

• Willingness and ability to take initiative and be a self-starter.

• Willingness and ability to understand and comply with Federal, State, and local regulations.

LICENSURE/CERTIFICATE/TRAINING:

• Current California RN license without restriction