**THIS POSITION ID HYBRID in Orange, CA **

Job Summary

Medical Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for PACE members . The Medical Case Manager (PACE) facilitates communication and coordination among all participants of the health care team as well as to the member and/or caregiver to ensure the services are provided to promote quality cost-effective This position will provide intensive case management in a process that includes but not limited to, planning, implementation, coordination, monitoring, tracking and evaluation of the members ;

Position Responsibilities

Performs comprehensive, disease specific, clinical assessment of all identified cases which includes but is not limited to assessment of:
- Member s physical, functional, social and psychological status;
- Member s cultural and linguistic needs;
- Caregiver resources and available
Develops and implements member specific care plans which include concrete prioritized, time-bound
Provides consistent and ongoing follow-ups to assess progress towards goals and identifies barriers to meeting
Communicates with members physicians, specialists, Skilled Nursing Facilities (SNFs), Assisted Living Facilities (ALFs), community agencies and other vendors to ensure coordination of
Collaborates with hospital discharge planners for a smooth transition in care for members who are
Prepares and maintains appropriate documentation of patient care and progress within the care plan following documenting
Facilitates Interdisciplinary Team (IDT) meetings and develops a plan, identifies options and goals when indicated through multi-disciplinary
Works collaboratively with interdepartmental staff in case
- Identifies cases needing Manager, Director or Medical Director review or input, and route
Advocates in the clients best interests for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and
Evaluates for medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits
Collaborates with PACE IDT and physicians in identifying high-risk patients, using criteria such as; patient s functional status, diagnoses, commorbidities, emergencies (ER), hospital utilization and social Monitors high-risk patients and provides appropriate interventions to mitigate
Assists with prior authorization, concurrent review, and retro authorization of service as

Possess the Ability To:

Maintain and ensure confidentiality of patient
Communicate clearly and concisely both verbally and written
Utilize computers, keyboarding, and appropriate software ( Microsoft Office applications and job-specific applications such as EHR) to produce correspondence, charts, spreadsheets, and/or other information applicable to the position

Requirements

Experience & Education

Associate s degree required ; Bachelor s degree in Nursing or related field is
Current RN license to practice in the State of California is
Minimum 2 years clinical experience working with the frail or elderly population Relevant experience must be within the last
3 years of case management and utilization experience
Experience with Milliman Care Guidelines (MCG)

Bilingual in English and in Spanish, Vietnamese, Korean, Farsi, Arabic, or Chinese is

Knowledge of:

Guidelines and regulations relevant to PACE, case management, utilization management and principles and practices of health care, health care systems, and medical
Legal and ethical issues pertaining to confidentiality in case
National Committee for Quality Assurance (NCQA) QI 7 Standards; Complex Case Management
Available community
Charting practices and
Available medical treatments and

Benefits

At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:

Competitive pay & weekly paychecks

Health, dental, vision, and life insurance

401(k) savings plan

Awards and recognition programs

Benefit eligibility is dependent on employment

Sunshine Enterprise USA is an Equal Opportunity Employer Minorities, Females, Veterans and Disabled Persons

Minimum 2 years clinical experience working with the frail or elderly population Relevant experience must be within the last 3 years of case management and utilization experience Experience with Milliman Care Guidelines (MCG) Bilingual in English and in Spanish, Vietnamese, Korean, Farsi, Arabic, or Chinese is Knowledge of: Guidelines and regulations relevant to PACE, case management, utilization management and principles and practices of health care, health care systems, and medical Legal and ethical issues pertaining to confidentiality in case National Committee for Quality Assurance (NCQA) QI 7 Standards; Complex Case Management Available community Charting practices and Available medical treatments and

Assistant professor of internal medicine