Clinical Care Manager


Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year. 

We know that by serving our employees well, they, in turn, will better serve our nearly 300,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

We are currently recruiting for:

Clinical Care Manager

POSITION SUMMARY

Works with internal and external health care team to provide clinical oversight of care coordination activities and promote effective and appropriate utilization of services and management of targeted members with high risk conditions. 

COMPLIANCE WITH REGULATIONS:

Works closely with all departments necessary to ensure that the utilization management processes, programs and services are accomplished in a timely and efficient manner, in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including Centers for Medicare and Medicaid (CMS) and/or Department of Health Care Services (DHCS).

RESPONSIBILITIES

  • Conducts home visits for identified members.

  • Clinical oversight of assigned caseload and care coordinators.

  • Uses clinical judgment to monitor, review and coordinate proposed inpatient, outpatient and specialty service requests for high risk adult and pediatric populations and determines covered benefits based upon lines of business benefit structures.

  • Develop and maintain accurate clinical documentation pertinent to member care coordination.

  • Document all activities required in CHG Net Case Management application and QNXT Call Tracking system.

  • Monitors inpatient and outpatient care and facilitates transition to the most appropriate levels of care as clinically appropriate.

  • Ensures that all identified high risk members have appropriate access and monitors compliance to treatment plans.

  • Contribute to the team effort, maintains member confidentiality.

  • Maintain company and product reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating in committees and meetings; performing other duties as required or assigned.

  • Conducts necessary outreach to high risk members for education on compliance with prescribed treatment plans.

  • Assists providers and staff in the identification of chronic care, high risk case management and disease specific management options for identified high risk members.

  • Participates in Quality Improvement Activities (QIA) activities. Forwards quality of care concerns to the QI Department and provides case-specific follow-up for pre- determined cases.

  • Researches and assists in the implementation of processes surrounding workflow and internal guideline development designed to enhance member outcomes and increase customer satisfaction.

  • Attends department meetings; provides feedback for existing processes; maintains patient confidentiality; represents department in interdepartmental and external meetings and forums on request.

  • Works closely with internal and external customers at assigned hospitals, clinics, and providers in order to facilitate and improve coordination of care.  Provides education to members and providers on available resources.  Offers assistance to peers when needed.

    Education:                 

  • Graduate from an accredited school of nursing or other health related field. 

  • BA degree in health-related field preferred.

  • Active California RN license required or comparable credential.

    Experience/Skills:    

  • 3 years of experience working in an acute care facility (ICU, emergency department, and/or medical/surgical unit) or outpatient health care setting and 1-year experience in a managed care environment, hospital discharge planning or outpatient clinic. Inpatient discharge planning or outpatient case management experience preferred.

  • Bilingual preferred; English/Spanish, English/Tagalog, English/Arabic, English/Vietnamese.

  • Knowledge of managed care principles preferred.

  • Experience with understanding and applying clinical guidelines.

  • Ability to communicate effectively verbally and in writing; exceptional telephone and customer service skills; ability to establish effective working relationships with physicians and medical professionals; ability to organize work effectively, determine priorities, and work well independently.