<div class="benefits">
<div><strong>Benefits:</strong></div>
<ul>
<li>401(k)</li>
<li>401(k) matching</li>
<li>Dental insurance</li>
<li>Health insurance</li>
<li>Vision insurance</li>
<li>Wellness resources</li>
</ul>
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<div class="trix-content">
<div>
<strong>Summary: </strong>Under the direct supervision of CCS Team Lead and CCS Supervisor, the CCS Nurse Case Manager- Case Review Liaison primarily reviews a case for CCS eligibility. He or she is responsible to assess, plan, implement, monitor, and evaluate options and services to develop a patient focused action plan. The CCS Nurse Case Manager-Case Review Liaison acts as patient advocate through the continuum and is available to the physician, patient and family as a resource to facilitate communication and efficient delivery of healthcare.<br><br>
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<strong>Duties & Responsibilities:<br></strong><br>
</div><div><br></div><div>• Primarily reviews CCS eligibility of outpatient service requests based on criteria set forth by California Code of Regulations Title 22, Division 2, Subdivision 7, Chapter 3, Article 2, Sections 41515.1-41518.9.<br><br>
</div><div>• Prioritizes outpatient cases needing prompt realignment to CCS paneled providers based on CCS eligibility review and effectively collaborating with Outpatient UM and Ambulatory Case Management Team as necessary.<br><br>
</div><div>• Reviews clinical records and contacts the member or member’s parent or guardian if necessary to further assess member’s social and health related needs and concerns.<br><br>
</div><div>• Reviews appropriateness of submitted claims for IPA payment or deferral to CCS if deemed eligible.<br><br>
</div><div>• Case manages CCS and DDS-RC cases and creates care plan goals to be discussed with the member or member’s parent or guardian, meeting all HP compliance requirements and audit needs.<br><br>
</div><div>• Makes sure that member or member’s parent or guardian is aware of the CCS or DDS case status, and fully understands the benefits that the programs offer.<br><br>
</div><div>• Delegates tasks to CCS Care Coordinator to outreach the member, specialist & PCP office for overall care coordination, and to check status of ancillary services like DME, therapy, home health if already provided to the member.<br><br>
</div><div>• Generates CCS referral guide sheet for the CCS coordinator in submitting SAR (Service Authorization Request) to CCS County office with supporting medical documentation.<br><br>
</div><div>• Gathers and organizes monthly, quarterly, or annual CCS reporting data within established timeframe as required for reporting purposes.<br><br>
</div><div>• Respects the dignity, confidentiality and privacy of each patient and adheres to HIPAA regulations and policies.<br><br>
</div><div>• Coordinates and completes special projects as delegated by the CCS Supervisor<br><br>
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<strong>Minimum Job Requirement: <br></strong><br>
</div><div>• Has Valid License in nursing (LVN/LPN, RN)<br><br>
</div><div>• Computer Proficiency on Microsoft Word, Excel and PowerPoint<br><br>
</div><div>• Good written and verbal communication skills<br><br>
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<strong>Skills & Abilities:<br></strong><br>
</div><div>• Analytical, proactive and a problem solver • Team player and professional<br><br>
</div><div>• Familiarity with medical guidelines and CCS criteria based on California Code of Regulations Title 22 is a<br><br>
</div><div>plus<br><br>
</div><div>• Knowledge and familiarity in using the EZCAP system is a plus<br><br>
</div><div>• Understanding of managed care philosophy, knowledge of HMO policies and procedures and managed care industry is a plus<br><br>
</div><div>• Detail oriented and excellent organization skills<br><br>
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<p>This is a remote position.</p>