Lead Care Management Specialist RN - FT - 567C

Job Description

The Care Management Specialist, Lead position functions as the lead of all staff in the Medical Management Unit and is responsible for daily operational activities, including staffing, productivity and work quality. Works with the Manager and Physician Advisor on case reviews for pre-service, concurrent post-service and retrospective claims medical review Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. The position also functions as the lead of all staff in the Care Management Unit and is responsible for daily operational activities, including staffing, productivity and work quality. The  Specialist, Lead is responsible for the day to day operations of the Telecommuting Program and the After Hours/Clinical Services program. 

The successful candidate must be organized and a team player with excellent communication skills, able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies. 

Additionally, the oversight responsibility of this position includes attendance at PPG UM Committee and Joint Operational Meetings (JOMs), monitoring of supplemental UM reports, reporting to management and UM Committee (UMC) and consultation/instructional/coaching activities to improve overall MM compliance with all regulations and standards.

Qualifications

EDUCATION

Required: Associate's Degree in Nursing

Preferred: Master's Degree in Nursing

LICENSES/CERTIFICATIONS

Required: Current and unrestricted CA RN License; Valid California driver's license and valid automobile insurance  

Preferred: Cert. in Case Management

EXPERIENCE

Required: Clinical Nursing 5 years. UM/CM-5 years.  Managed Care- 3 years; Medi-Cal - 2 years and excellent interpersonal and communication skills. Managerial experience, direct or indirect, minimum of 2 years; in lieu of experience, will participate in a management mentoring program.  Good working knowledge of regulatory requirements/standards. Computer literacy and adaptability to computer learning. Time management and priority setting skills.

Special Instructions

Req. Number: 567C