RN, Clinical Care Manager I

Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

POSITION SUMMARY

The Gold Coast Health Plan (GCHP) RN, Clinical Care Manager I supports the GCHP mission to improve the health of the members through provision of the best possible quality care and services. As defined by the Case Management Society of America (CMSA): Care management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes. 

The RN, Clinical Care Manager I works closely with other team members and is a role model and resource to colleagues. This position acts as a bridge by facilitating communication between the member, member’s family and the providers. The RN, Clinical Care Manager I also provides member advocacy and education to maintain or improve clinical outcomes.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statements

•    Promote the most cost-effective healthcare delivery by coordinating with the medical management team.

•    Engage members into care coordination activities to reduce care gaps.

•    Evaluate for and work toward elimination of barriers to care.

•    Formulation of a member-centric care plan in partnership with the member.

•    Facilitate reduction of inappropriate utilization of the ER, urgent care and frequent hospitalizations.

•    Facilitate and encourage member use of the Medical Home (PCP).

•    Assist the member with their physician prescribed treatment plan to facilitate understanding and promote improved adherence.

•    Identify benefit structure and educate member regarding management of available benefits

•    Work in concert with other Health Services team members to optimize outcomes.

•    Ensure confidentiality of utilization review, quality assurance information, and individual beneficiary identification. 

•    Assist with data collection for special member determination as required.

•    Prepare written reports such as summaries of case management functions and updates of case status, use of covered services, supporting and reporting required metrics and other pertinent performance data, as directed.

•    Provide accurate documentation to meet departmental policies, regulatory requirements and audits.

•    Attend community meetings concerning health issues or provision of health-related services.

•    Adhere to all GCHP Policies and Procedures and meet required performance standards.

•    Establish and maintain effective working relationships with community resources and service agencies.

•    Other duties as assigned by manager/director

•    Relationship management skills, including non-aggressive assertiveness

•    Ability to engage easily in abstract thought

•    Ability to successfully manage conflict, negotiating “win-win” solutions

•    Strong organizational, delegation and task prioritization skills

•    Member advocacy focus

•    Knowledge of required regulatory timelines to ensure department compliance with State contracts

•    Ability to convey empathy and is nonjudgmental of the member

•    Demonstrates team support by consistently seeking opportunities to recognize and promote colleagues

•    Ability to stay calm and professional when working with internal and external partners.

•    Ability to multi-task, both with and without supervision, with attention to detail 

•    Works collaboratively with external and internal customers

•    Exhibits accountability by maintaining good attendance

POSITION QUALIFICATIONS 

Competency Statements

•    Customer Oriented - Ability to take care of the customers’ needs while following company procedures.

•    Communication, Oral - Ability to communicate effectively with others using the spoken word.

•    Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

SKILLS & ABILITIES

Education:    

•    Bachelor's Degree (four-year college or technical school) is preferred, Field of Study: in a health-related field and managed care experience is desired

•    Registered Nurse (RN) valid and current license.

•    CCM certification preferred

Experience:    

•    2 plus years of experience in the health care field required.

•    Care management, discharge planning, or equivalent combination of education and experience preferred.

•    Managed care experience in a health plan preferred.

•    Certain positions may require bilingual skills in English and Spanish.

•    Computer Skills: Strong computer skills on Microsoft Office products and data base programs (Word, Excel, Outlook, Teams, PowerPoint would be a plus)

Certifications & Licenses:

•    Active, valid and unrestricted CA Registered Nurse license

•    CCM or other CM certification preferred   

SKILLS, KNOWLEDGE & ABILITIES

Desired:

•    An attitude to excel, a special empathy for working with multiple populations, an investigative personality and a willingness to mentor colleagues.

•    A working knowledge of Medi-Cal and related policy and regulations.

Required:

•    Ability to evaluate clinical and other health data and to communicate effectively both orally and in writing.

•    Ability to synthesize thoughts and plans succinctly in writing. 

•    Ability to balance multiple tasks.

•    Strong organizational skills. Critical thinking skills.

•    Flexibility in role delineation and workload assignments. 

•    Team player.