Lead Care Management Specialist

Job Category:  Clinical
Department:  Care Management (641)
Location:  Los Angeles HQ, California, US
Position Type:  Full Time
Requisition ID:  510

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

DUTIES
The Care Management(CM) Specialist Team Lead position functions as the lead of Care Management Specialists in the Care Management MCLA Department, in support of the Care Management Supervisor.  Demonstrates and reinforces in-depth knowledge of the CMSA Case Management Standards of Practice as well as the L. A. Care Policies / Procedures.  The Team Lead supports the Supervisor with monitoring team work quality, performance, and productivity. The Team Lead performs first-level problem solving for staff in addressing questions / issues related to specific cases, system issues, and policy / procedure interpretations.  Escalates cases to Supervisor as needed to determine timely and appropriate disposition.  Performs staff internal quality audits on a regular basis to monitor implementation of NCQA and DHCS standards / guidelines and reports findings to Supervisor.  Is able to coach to gaps detected on audits; is able to educate staff on the internal quality review / audit processes.  Facilitates external audits (including NCQA, DHCS) through case organization and prep, tagging, flipping cases during active audits, and follow/up post audit. Able to demonstrate and reinforce in-depth knowledge of the CMSA Case Management Standards of Practice. Stays abreast of system of record changes and training as well as updates in case management processes, policies and procedures by maintaining a limited case load.   Monitors / evaluates cases being submitted for weekly Interdisciplinary Care Team meetings, conducts weekly ICT meetings per schedule.   Assists with the training program for new hire Care Management Specialists.  Participates in programs and projects as directed / approved by Supervisor.

QUALIFICATIONS & REQUIREMENTS
 
EDUCATION

Required
Degree from accredited nursing program
Associate or Bachelor's Degree in Nursing

Preferred
Master's Degree in Nursing
 
LICENSES/CERTIFICATIONS
Required
Current and unrestricted CA RN License
Valid California driver's license and valid automobile insurance 
 
Preferred
Cert. in Case Management
 
EXPERIENCE
Required
5 years of clinical experience in Utilization or Care Management in a hospital or ambulatory setting with the demonstrated experience/ knowledge / skills on the following:  

Managed Care - 2 years; Medi-Cal - 2 years and lead/ supervisory experience. In lieu of lead/ supervisory experience, will participate in a management mentoring program.

Excellent interpersonal and communication skills.   
Experience mentoring and/or training staff.  
Good working knowledge of regulatory requirements / standards. 
Computer literacy and adaptability to computer learning. 
Time management and priority setting skills.
 Must be organized and a team player 
Excellent verbal and written communication skills 
Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies. 
Persuasion Skills:  Utilizes medical knowledge and experience to evaluate the medical necessity of any requested service.  Demonstrated ability to provide physician advisors with all the applicable medical information and criteria research for review to support a timely determination.

L.A. Care offer a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program


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