CCS (California Children’s Services) Nurse Case Manager, Case Review Liaison

Summary

Under the direct supervision of CCS Team Lead and CCS Supervisor, the CCS Nurse Case Manager- Case Review Liaison primarily reviews a case for CCS eligibility. He or she is responsible to assess, plan, implement, monitor, and evaluate options and services to develop a patient focused action plan. The CCS Nurse Case Manager-Case Review Liaison acts as patient advocate through the continuum and is available to the physician, patient and family as a resource to facilitate communication and efficient delivery of healthcare.

Duties and Responsibilities:

• Primarily reviews CCS eligibility of outpatient service requests based on criteria set forth by California Code of Regulations Title 22, Division 2, Subdivision 7, Chapter 3, Article 2, Sections 41515.1-41518.9.
• Prioritizes outpatient cases needing prompt realignment to CCS paneled providers based on CCS eligibility review and effectively collaborating with Outpatient UM and Ambulatory Case Management Team as necessary.
• Reviews clinical records and contacts the member or member’s parent or guardian if necessary to further assess member’s social and health related needs and concerns.
• Reviews appropriateness of submitted claims for IPA payment or deferral to CCS if deemed eligible.
• Case manages CCS and DDS-RC cases and creates care plan goals to be discussed with the member or member’s parent or guardian, meeting all HP compliance requirements and audit needs.
• Makes sure that member or member’s parent or guardian is aware of the CCS or DDS case status, and fully understands the benefits that the programs offer.
• Delegates tasks to CCS Care Coordinator to outreach the member, specialist & PCP office for overall care coordination, and to check status of ancillary services like DME, therapy, home health if already provided to the member.
• Generates CCS referral guide sheet for the CCS coordinator in submitting SAR (Service Authorization Request) to CCS County office with supporting medical documentation.
• Gathers and organizes monthly, quarterly, or annual CCS reporting data within established timeframe as required for reporting purposes.
• Respects the dignity, confidentiality and privacy of each patient and adheres to HIPAA regulations and policies.
• Coordinates and completes special projects as delegated by the CCS Supervisor

Minimum Job Requirements:

• Has Valid License in nursing (LVN/LPN, RN)
• Computer Proficiency on Microsoft Word, Excel and PowerPoint 
• Good written and verbal communication skills 

Skills and Abilities:

• Analytical, proactive and a problem solver 
• Team player and professional 
• Familiarity with medical guidelines and CCS criteria based on California Code of Regulations Title 22 is a plus 
• Knowledge and familiarity in using the EZCAP system is a plus
• Understanding of managed care philosophy, knowledge of HMO policies and procedures and managed care industry is a plus 
• Detail oriented and excellent organization skills

Salary Range:

• $35 – $40 hourly