Care Management Specialist II
Los Angeles, CA, US, 90017
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
The Care Management Specialist II performs essential functions of care management for identified and assigned member population according to Health Insurance Portability and Accountability Act (HIPAA) guidelines. Manages a specified caseload; coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner. Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefit: Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team. Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines. Uses claims processing and care management software to look up member information, document contacts, and track member progress.
Evaluates information regarding prospective care management members referred by health risk assessment (HRA), risk stratification, predictive modeling, provider's utilization review vendors, members, Call Center, claims staff, HHP eligibility or other data sources to determine whether care management intervention is necessary to meet the member's needs.
Care Management services for the member include: maintaining assigned care management case load, member centric communication which includes the interdisciplinary team, providers and family or authorized representatives. Reviews member claims histories and identifies intervention opportunities through the professional standards of practice. Contacts and interviews members to conduct a baseline assessment, assess self-care ability, assess knowledge and adherence deficits. Develops a member centric plan of care.
Collaborates with primary care physician and other treating professionals as appropriate. Authorizes initiation of care management services and specialized program services for members and specific populations, and develops interventions designed to meet member or population desired outcomes. Educates members about accessing services, in-network use, national guidelines for care, community resources, and self-management skills and strategies.
Employs engagement techniques to build relationships with members and their authorized representatives. Encourages participants to participate in their health care decisions and assists member with researching treatment options in order to communicate effectively with providers and to make informed decisions.
Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) regarding benefit approvals and denials. Notifies Care Coordinators and CHWs of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines.
Demonstrates effective care management for Individualized Care Plan summary and interventions during the Interdisciplinary Care Team meetings based on department guidelines.
Facilitates appropriate use of resources and coordinates necessary services to improve health status and impact the cost of care. Identifies member needs for and refers to appropriate internal and external programs, as appropriate.
Encourages member and family empowerment through education and use of reliable resources.
Monitors and evaluates member progress: evaluates member-response to interventions and refines action plan to produce desired outcomes. Identifies complex care management issues and discusses possible solutions with management. Assess effectiveness of care plan's goals and interventions on a regular basis.
Uses claims and care management software to document interactions and interventions with members, vendors, and providers. Maintains case information in the member's clinical records to promote care coordination.
Provides ongoing direction and support to internal customers regarding Care Management programs, processes, and benefit coverage.
Responsible for staying current with best practices, identifying areas for personal growth opportunities and works with management to develop a plan for obtaining the necessary training.
Perform other duties as assigned.
Master's Degree in Social Work
In lieu of degree, equivalent education and/or experience may be considered.
Bachelor's Degree in Nursing
Minimum of 3 years of recent care management experience in a hospital or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments.
Requires current knowledge of clinical standards of care and disease processes.
Requires critical thinking skills, effective verbal and written communications skills to consult with physicians and providers.
Requires the ability to use a personal computer, and knowledge of medical information systems.
Active & Current Driver's License, with a clean record and Auto Insurance Required
Licensed Clinical Social Worker (LCSW) - Active, current and unrestricted California License
Registered Nurse (RN) - Active, current and unrestricted California License
Certified Case Manager (CCM)
A Licensed Clinical Social Worker is only required with Master's Degree in Social Work.
Licensed Clinical Social Worker is not required with an Associate's or Bachelor's Degree in Nursing.
L.A. Care offers a wide range of benefits including
+ Paid Time Off (PTO)
+ Tuition Reimbursement
+ Retirement Plans
+ Medical, Dental and Vision
+ Wellness Program
+ Volunteer Time Off (VTO)