Community Supports, Nurse / Job Req 738473224 at ALAMEDA ALLIANCE FOR HEALTH in Alameda, California

Job Description:

PRINCIPAL RESPONSIBILITIES:
This position works under the direct supervision of the Supervisor, Community Supports (CS) and is responsible for evaluating the clinical presentation of members in need of Community Supports services.This role utilizes the applicable clinical practice standards/guidelines to determine medical necessty for the service required by the member.

The Community Supports (CS) Nurse processses clinical, psychsocial and social determinants of health information to ensure that members receive the appropriate service. The position provides expert guidance to community providers, community based organizations, hospital staff, and other internal and external partners on appropriate resources available to members to achieve the optimal functioning, stability and autonomy. The CS Nurse will be working closely with a team comprised of the Coordinators and external CS Providers in the community. The goal of Community Supports services is to offer services or settings in place of services or settings covered under Medi-Cal and that are medically appropriate, cost-effective alternative to a Medi-Cal Covered service.

Principal responsibilities include:
Review of prospective, inpatient or retrospective medical records of services for medical necessity Consultation with the Alliance Medical Director to validate patient acuity and plan of care as needed; Extrapolate and summarize medical information for Medical Director, consultants or other external review entities. Apply clinical medical necessity guidelines, policy and procedures, and EOC benefit guidelines. Prepare recommendations to either approve or deny, and forward recommendations for denial of payment to Medical Director for review. The nurse will act a subject matter expert on the nursing process and perspective for the Community Supports team. The nurse will be responsible for triage and all aspects of the nursing process, including assessing, diagnosing, planning, implementing, and evaluating care. Document and log clinical information, guidelines, referrals and actions taken in relevant tracking systems. Use clinical judgment to assess and stratify members for appropriate levels of need and refer members to the Case and Disease Management Department and the Enhanced Care Management (ECM) team as necessary.

Participate in the ongoing process of a identifying the health plans members who are most at-risk of poor health outcomes and in need of care management services. Participate in recurring multidisciplinary care team meetings with AAH Case Management team and be able to present guidence and support Work collaboratively with the health plans providers, including members primary care providers and specialists, and community based organizations to provide highly coordinated care. Assess member medical and social determinants of health; including housing status and other Community Supports, as part of chart reviews and multidisciplinary care team meetings. Serve as primary clinical reviewer for Community Supports reviews for CS services. Collaborate in a positive interdisciplinary approach with other Case Managers and CM/DM staff, Utilization Management, Provider Services, Member Services departments as well as community resources to ensure the most appropriate level of care and optimal outcomes.

Communicate with providers, members, and community resources as necessary, to support the planning, implementation and evaluation of Community Supports services. Employ a patient advocacy approach with a seamless integration of services, balanced within the member's benefit structure Demonstrate a comprehensive understanding of coverage and benefits to promote appropriate service utilization and increase participant, member, and patient knowledge and satisfaction. Recognize and resolve continuity of care issues or other problem areas promptly. Educate and answer inquiries from participants, patients, and members and/or their family members about benefits, services, eligibility, and referrals with a positive and professional approach, promoting participant, patient, and member satisfaction and retention. Demonstrate a patient-centered approach to self-management skills for chronic disease conditions and provide decision support, urgent care support, symptom management support, basic health and wellness information, and educational resources. Identify and provide appropriate community referrals for participants, patients, and members, facilitating access to appropriate support services, including medical and social resources to address presenting issues and assist in the removal of barriers. Assist the Director of Social Determinants of Health in tracking utilization and operational trends and implementing solutions. Work with various departments at the Alliance to resolve inquiries into claims, authorizations, and eligibility. Utilize leadership skills and serve as a subject matter expert for clinical criteria, Community Supports services issues and is a resource for AAH and community partners clinical and non-clinical team members in expediting the resolution of outstanding issues. Identify system issues that result in failure to provide appropriate care to members or failure to meet service expectations and make recommendations for improvement. Assist with outreach, planning, and execution of regular Learning Collaboratives. If appropriate, work with state and federal eligibility and enrollment staff/vendors to assist in continuity in enrollment. Complete other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
Communicate and coordinate required services for members with PCPs, CS Provider, specialists, and community-based organizations. Manage, document, and maintain casework in accordance with NCQA accreditation guidelines and state regulators. Build and maintain effective relationships with designated CS Providers and community-based organizations. Evaluating clinical presentation against clinical guidelines and applicable regulatory requirements. Maintain case management records.
Serve as a clinical resource to staff, as needed. Perform writing, administration, analysis, and report preparation. Research and develop working relationships with appropriate community resources to service members. Provide direction to ancillary team staff members who will provide additional coordination activities for health plan members being case managed. Communicating effectively, both verbally and in writing. Comply with the organizations Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
PHYSICAL REQUIREMENTS
Constant and close visual work at a desk or a computer. Constant sitting and working at a desk. Constant data entry using keyboard and/or mouse. Frequent use of telephone headset. Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. Frequent lifting of folders and other objects weighing between 0 and 30 lbs. Frequent walking and standing.
Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:
Bachelors degree required, BSN or MSN strongly preferred. Registered Nurse license, active and unrestricted licensed in the State of California before start of work.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
Three years of clinical experience in an acute care setting required. Three years experience in managed care or health care setting preferred. Masters in Case Management will be considered in lieu of the above listed required clinical CM and desired acute experience. Milliman Care Guidelines (MCG), Managed Care and DHCS/NCQA experience preferred.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

Excellent verbal and written communications skills. Fluency in English required. Fluency in Vietnamese, Cantonese, Spanish, Tagalog, or other appropriate language preferred. Ability to work within guidelines and protocols to achieve decisions independently. Excellent critical thinking and problem-solving skills. Ability to work in cooperation with others. Knowledge of Medi-Cal and Medicare regulations a plus. Ability to motivate. Knowledge of and experience with community and other resources a plus Ability to act as a resource to department staff. Maintain continuous current nursing license required. Proficient experience in Windows including current Microsoft Office suite. Experience in Care Management Software applications a plus.
SALARY RANGE 105,853.04-$158,779.55 Annually
The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.