job

About Us:

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.

About the role:

The RN Case Manager is responsible for providing on-going case management services for Santa Clara Family Health Plan (SCFHP) members. As a SCFHP member advocate, the RN Case Manager facilitates communication and coordination among all participants of the care team to ensure member identified goals and needed services are provided to promote quality cost-effective outcomes. Through the development and implementation of member individualized care plans, the RN Case Manager provides medical and psychosocial case management support to help coordinate resources and services for individuals across the healthcare and social services continuum, and facilitate the use of available healthcare benefits in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.

Day to Day:

Conduct, review and document comprehensive clinical and/or psychosocial assessments and on-going follow-up interventions to measure progress towards meeting goals as they relate to a member’s physical, psychosocial, environmental, safety, developmental, cultural and linguistic needs.

Maintain case files by assuring that they are documented in accordance with SCFHP policies and procedures, and state and federal requirements and organized in a manner that adheres to standards for audit requirements.

Facilitate involvement of the member and/or family/responsible party for the development and implementation of a member-specific care plan which includes individualized prioritized goals.

Coordinate member’s care with PCP, Specialists, Behavioral Health and Long Term Services and Supports providers to assist member to achieve or maintain a level of functional independence which allows them to remain at home or in the community.

Facilitate and coordinate communication with member’s interdisciplinary care team including SCFHP internal staff, as well as the member’s physicians, specialists, public services, community agencies and vendors to ensure care plan development and coordination of benefits and services.

Facilitate successful transition of care for members who move between care settings by coordinating services for medical appointments, pharmacy assistance and by facilitating utilization review.

If assigned to MLTSS, support the transition of long-term care members residing in nursing facilities to a lower level of care, or community setting in partnership with MLTSS providers and programs.

If assigned to Community Based Adult Services (CBAS): Conduct face-to-face, on-site eligibility determinations for CBAS services with members using the standardized California Department of Health Services approved tool – CBAS Eligibility Determination Tool (CEDT) & Patient Health Record Quick Guide; Review and approve Individual Plan of Care for CBAS members; and Provide care coordination to targeted CBAS members including assessment, care plan implementation and care transitions. Conduct telephonic and/or visits/assessments, as needed in the home, facility or community setting.

About you:

Active California RN License without restriction.

Minimum three years of experience in case management, discharge planning, or education or certifications, or equivalent experience.

Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management.

Clinical knowledge and critical thinking skills with the ability to assess individualized whole-person care needs necessary to develop an effective care plan.

Ability to conduct home, facility and other community-based visits.

Maintenance of a valid California driver’s license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events.

Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs.

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