The Care Management Specialist II utilizes clinical skills and training to perform essential functions of care management for identified and assigned member population according to Health Insurance Portability and Accountability Act (HIPAA) guidelines. 

Manages a specified caseload across the entire continuum of programmatic levels including those within National Committee for Quality Assurance (NCQA) scope or otherwise Complex/Catastrophic cases, which are those with the severest acuities or care needs and requiring the highest clinical skills and judgement.  

Management of the caseload assigned by Manager includes: coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner.  

Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefit: Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team.

Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines. Uses claims processing and care management software to look up member informa…

Qualifications

Education Required:

• Associate's Degree in Nursing for Registered Nurses
• Master's Degree in Social Work for Licensed Clinical Social Workers

Education Preferred:

• Bachelor's Degree in Nursing for Registered Nurses

Experience Required:

• Minimum of 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments.   
• Experience providing care management with complex/catastrophic conditions.

About the Hospital

As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.

Why Join Us?
Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.