JOB OBJECTIVE

Under the general supervision of the Medical Management Director, the Enhanced Care  Management Nurse (ECM) provides efficient and effective Care Management to qualified members by addressing the member’s medical, physical, and psychosocial needs. Using clinical judgement and critical thinking skills, the ECM Nurse develops, modifies and assists the member to implement their care plan and ensure all tasks are timely and in compliance with time requirements per Model of Care/Health plan/DHCS regulatory requirements.

 

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

The ECM Nurse’s responsibilities include, but are not limited to:

• Comply with organization and department policies & procedures and Model of Care to ensure all appropriate services for the eligible population are completed and acted upon within established timeframes.
• Collaborate with a team of Community healthcare workers to address social needs.
• Manage a case load of 50 Medi-Cal members with complex needs.
• Adhere to DHCS requirements to include outreach within required time frame, comprehensive assessment, care plan creation to address all medical and social needs, ICT performance, coordination of care for all transitions of care. 
• Review medical records and community assessments for member history and care planning.
• Coordinate care to ensure a seamless experience for the member with non-duplication of services.
• Perform medication reconciliations per initial assessments and transitions of care.
• Offer services where the member lives, seeks care, or finds most easily accessible and within health plan guidelines.
• Connect members to other social services and support, including transportation services, and provide referrals as appropriate.
• Use motivational interviewing, trauma- informed care, and harm-reduction approaches.
• Coordinate with hospital staff on discharge plan and coordination of care.
• Accompany members to office visits as needed and according to Health Plan guidelines.
• Monitor treatment adherence.
• Provide health promotion and self- management training.
• Evaluate assessment findings against evidenced-based guidelines to develop a plan of care based on member needs and findings with collaboration from interdisciplinary team.
• Identify potential barriers to adherence to treatment plan and modify plan by mutual agreement with the member.
• Educate member/caregiver on specific disease using approved evidence-based guideline and modify plan of care/goals based on member’s readiness to change.
• Facilitates care coordination across the care continuum (home, hospital, home health)
• Assesses cultural and linguistic needs and preferences.
• Consistently documents activities and interventions provided to members.
• Attends/participates in interdisciplinary team meetings.
• Provides member with support telephonically to ensure appropriate utilization of benefits, treatment and plan of care, and member’s understanding of healthcare system.
• Participates in all health plan audits and seminars as applicable.
• Develop a working relation with internal departments to maintain the flow of needed information.
• Submit reports of productivity as applicable.
• Maintains the member’s right to privacy and protects by keeping information confidential.

EDUCATION, EXPERIENCE AND QUALIFICATIONS

• Current and active California license, RN or MSW with experience and training.
• Experience with clinical issues and guidelines.
• Excellent analytical, critical reasoning, organizational and interpersonal communication skills
• Strong written and oral communication skills
• Ability to multi-task and work autonomously
• Ability to keep a high level of confidence and discretion when dealing with sensitive matters relating to providers, members, business plans, strategies and other sensitive information is required.
• Proficient with Microsoft Office (Word, Excel, Power Point), CM Data Bases
• Knowledge of enhanced case management, SNP case management, complex case management
• Experience in managed care environment – health plans, IPA, or MSO
• 1+ years of Case Manager experience
• Basic knowledge of DHCS-Medi-Cal standards