Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.
Trains, audits, supervises and coaches CM staff. Informs supervisors of trends to address performance opportunities and/or counseling/corrective action to ensure the team's training needs are met and there is a thorough understanding and application of regulatory requirements and CalOptima policies.
Identifies new learning opportunities for staff such as developing training materials (e.g., workflows, desktop procedures, PowerPoint presentations, training plans and calendar activities) to provide education.
Identifies training needs within CM and creates presentations that convey the concepts, as well as provides examples to demonstrate the topic of discussion and validate knowledge of the trainees. Trainings will be a combination of in-person, self-paced and virtual modalities depending on the curriculum and the needs of the trainee.
Uses systems demos, screen prints and desktop tools to help team members with consistent adoption of workflows in the clinical system.
Ensures understanding of application of medical necessity criteria through multidisciplinary forums whereby case discussion and application of criteria occur including cross functional inter-rater reliability sessions with Medical Directors.
Assists with the collection, monitoring and analysis of CM indicators and activities to develop training curriculum that addresses the needs of the department.
Ensure staff have needed training on CM processes including but not limited to; Health Risk Assessments (HRA), Individualized Care Plans (ICP), Interdisciplinary Care Team (ICT), documentation, Long Term Services and Supports (LTSS) and other areas.
Provides training on the philosophies of Person-Centered Planning and Motivational Interviewing.
Works collaboratively with CM management to ensure appropriate trainings are developed and delivered to staff.
Spearheads the onboarding process for all CM staff to ensure effective training techniques to guarantee understanding and concepts.
Provides training and guidance for all CalOptima policy changes as well as regulatory communications, such as All Plan Letters (APLs), Whole Child Model (WCM) Numbered letters, National Committee for Quality Assurance (NCQA) requirements and CMS program communications.
Serves as a resource to departmental staff, internal departments and affiliated health networks regarding authorization rules, processes and CalOptima policy.
Evaluates training effectiveness to ensure staff understanding and readiness.
Reeducates staff when deficiencies in performance are identified.
Provides training for system implementation and updates.
Reviews workflows, procedures, and/or policies to ensure alignment and recommend or change as appropriate.
Conducts CM presentations to internal or external customers.
Completes other projects and duties as assigned.
Requirements :
Bachelor's degree in Nursing or related field required.
Certified Case Manager (CCM) certification required.
5 years of experience in clinical nursing and/or managed care required
3 years of experience training in CM concepts and principles required.