We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The scope of the High-Risk Case Manager is to effectively manage members on an outpatient basis to ensure the appropriate level-of-care is provided for complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care to prevent re-admissions and ensure that the members’ medical, environmental and psychosocial needs are optimize over the continuum of care.

Job Responsibilities/Duties

• Provides appropriate documentation including but not limited to; cognitive, functional, ADL, environmental factors, psychosocial, medical and benefits etc.
• Interfaces with Medical Director and attends IDT as required.
• Collaborate and coordinate care with Health plans, Community Based Programs (CBAS), Managed Long Term Supportive Services (MLTSS) and Behavioral Health Providers
• Conducts outbound calls to assigned high risk case managed members. Occasional, in person visit may be needed to better facilitate members’ care.
• Monitors and evaluate effectiveness of the care management plan and modify as necessary based on members’ progress, changes in condition and to minimize unnecessary utilizations, admissions, and readmissions.
• Develop Individual Care Plan (ICP) by conditions identified in health plan HRA, patient assessment, medical records authorizations/referrals, primary care physician, member, and Interdisciplinary Care Team (ICT). Setting members prioritized and self-management goals.
• Collaborate with member’s family and physicians for seamless coordination of care and services
• Collaborate and coordinate care with health plans, Community Based Programs (CBAS), Multiple Long Term Support Services (MLTSS) and Behavioral Health providers.
• Case Manager’s ability to effectively manage a panel/caseload of high-risk members in collaboration with Nurse Practitioner, Pharmacist, PCP, SPC, health plans and other ICT members.
• Meet health plans and NCQA requirements in turn-around-time for assessments, care plans and IDTs.
• Identifies appropriate members for case management and conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
• Collaborate with member, member’s family, and physicians for seamless coordination of care and services.
• Create cases in Essette for each case managed member with appropriate documentation including but not limited to; cognitive, functional, ADL, environmental factors, psychosocial, medical and benefits etc.

Qualifications

Minimum Education: None.

Minimum Experience: At least two (2) years’ experience in the medical field required. One (1) year experience in a case management role required. At least two (2) years’ experience in ambulatory case management, preferably in a managed care organization, medical group, or health plan setting required. Knowledgeable in NCQA requirements preferred.

Req. Certification/Licensure: RN/LVN unrestricted active license required. CCM Certification preferred.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:

• Company 401K
• Medical, dental, vision insurance
• Paid time-off
• Life insurance

How to Apply

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www.eeoc.gov/