This job is closed
Applications are no longer available for this announcement. Explore current related opportunities below.
Job description
Care Management – Overview
The Care Management team independently manages complex and high‑risk care management cases by applying advanced clinical judgment to assess medical necessity, develops cost‑effective care plans, supports quality outcomes aligned with benefit and contract requirements, and coordinates care with providers, medical directors, and interdisciplinary teams. The role requires ongoing reassessment, awareness of healthcare trends and clinical guidelines, and participation in a rotating evening and weekend on‑call schedule.
Responsibilities
Work with minimal supervision to manage complex care management cases
Apply advanced clinical judgment to assess medical necessity and appropriateness of care
Design and implement treatment and care plans that promote quality, cost‑effective outcomes aligned with benefit and contract requirements
Coordinate discharge planning activities for complex and high‑risk cases
Determine appropriateness of referrals to care management and specialty programs
Collaborate with providers, medical directors, and interdisciplinary teams to support member treatment plans and care continuity
Evaluate member health behaviors, cultural influences, and belief systems to identify barriers to care
Contribute clinical input to medical directors and support informed decision making
Continuously improve outcomes by anticipating barriers and adjusting plans of care based on reassessment, clinical changes, and guideline updates
Maintain current knowledge of healthcare service trends, regulations, and clinical practice guidelines
Work evenings and weekends as part of rotating on‑call schedule
Perform other duties as assigned
Qualifications
Associate Degree in Nursing required or master’s degree in a relevant field for non‑RN licensure
Bachelor of Science in Nursing is preferred
5 years of experience in nursing, healthcare, or a related clinical field
3 years of managed care experience preferred
Certified Case Manager (CCM) is preferred
Ability to independently assess, evaluate, and interpret complex clinical information and care plans
Advanced knowledge of evidence‑based clinical practice guidelines, particularly for chronic conditions
Demonstrated competence in care management functions and standards of practice
Knowledge of community resources, treatment options, home health services, funding sources, and specialty programs
Working knowledge of regulatory and accreditation standards including CMS, DHCS, URAC, NCQA, DMHC, MHPAEA, and CA SB 855 is preferred
Knowledge of coordination of care, government and commercial regulations, prior authorization processes, and level of care and length of stay criteria is preferred
Hybrid Virtual Work
This role allows employees to work virtually full‑time; however, employees will be expected to come to the office based on business needs.
Job Information
Job Identification:
Job Category: Healthcare Services and Operations
Job Schedule: Full time
Locations: El Dorado Hills, CA; Long Beach, CA; Lodi, CA; Oakland, CA; Rancho Cordova, CA; Redding, CA; San Diego, CA; Woodland Hills, CA
Pay Range for California: $90,860.00 to $136,290.00
Pay Range for Bay Area: $102,424.00 to $153,636.00
Role can be filled by a candidate requiring sponsorship: No
Physical Requirements
Office Environment – roles involving part to full time schedule in an office environment. Based in physical offices and work from home office/deskwork – activity level: sedentary, most of work day.
Equal Employment Opportunity
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
#J-18808-Ljbffr
Worksite address
california, MO, 65018, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.