Managed Long Term Services and Supports Nurse Specialist RN II

Job Summary

The Managed Long-Term Services and Supports (MLTSS) Nurse Specialist RN II applies advanced clinical judgment and critical thinking skills to facilitate appropriate physical and behavioral healthcare and social services for L.A. Care members. Utilizes assessments, member-centered care planning, direct provider coordination/collaboration and psychosocial wraparound services to promote effective utilization of available Health Plan benefits including, but not limited to Community Based Adult Services (CBAS), Skilled Nursing Facility (SNF) services, Intermediate Care Facility for Developmentally Disabled (ICF/DD) services, CalAIM Community Supports, Palliative and Hospice Care. Scope of work includes care coordination functions and must adhere to regulatory mandates that apply to Utilization Management (UM) and Care Management (CM).

This position is responsible for assessing, planning, coordinating, and monitoring care needs to ensure members receive high-quality, cost-effective care that promotes independence and quality of life.  The MLTSS Nurse Specialist RN II conducts comprehensive health assessments and is a member of an interdisciplinary team that is key in identifying the physical, psychological and social needs of the member. 

The MLTSS Nurse Specialist RN II collaborates with Skilled Nursing Facilities (SNF), Intermediate Care Facility - Developmentally Disabled (ICF-DD), Community Based Adult Services (CBAS) Centers, Residential Care Facilities for the Elderly (RCFE), Preferred Provider Groups (PPG), CalAIM providers (i.e. Community Supports Vendors), Palliative and Hospice Care Providers and cross functional units to facilitate coordination of services.

Duties

Responsible for performing assessments and clinical review of medical records to determine appropriate care including physical health, behavioral health, and social determinants of health needs for members referred to; MLTSS administered programs.

Responsible for UM authorization functions for services requiring prior authorizations in a timely manner with adherence to regulatory requirements. Identify and address gaps in care or overutilization, including overlapping services.

Engages with members by conducting telephonic nursing follow up and care coordination when necessary, including transitions of care for Long Term Care (LTC) and ICF/DD populations. 

Provides direction to non-clinicians who assist members with accessing services and arranges for all services required while coordinating with the health care team to eliminate duplication of services.

Interfaces with Medical Directors, social workers, and interdisciplinary care team (ICT). Participates in ICT meetings and makes recommendations for MLTSS and other programs.

Establishes relationships with referral sources and community resources, such as external providers and care coordinators, while maintaining strict member confidentiality and complying with all Health Insurance Portability and Accountability Act (HIPAA) requirements. 

Performs oversight and monitoring of provider performance for adherence to regulatory standards and contractual agreements. Participate in provider audits and quality improvement initiatives. Partners with Provider Network Management (PNM) and participates in Joint Operations Meetings (JOM).  

Duties Continued

Facilitates care coordination with and provides education on available services to internal and external entities to improve member's short- and long-term goals in collaboration with member, caregivers, family, support systems, and physicians. A person-centered approach minimizes member confusion, and ensures the best care is delivered in the most appropriate setting.

Documents accurately and comprehensively based on the standards of practice and current organization policies.

Performs other CM and UM functions as assigned and as needed /required by L.A. Care, to maintain regulatory requirements and company objectives.

Performs other duties as assigned. 

Education Required

Education Preferred

Experience

Required:

At least 3 years of clinical nursing experience in direct patient care, such as ambulatory care, home care, palliative care, hospice care OR experience in Utilization Review or Care Management will be considered in lieu of direct patient care that may include at least 2 years of relevant Licensed Vocational Nurse (LVN) experience in a UM or CM capacity substituted for 1 year of RN experience.

Clinical experience working with individuals with chronic illnesses, comorbidities, and/or disabilities in a UM/CM environment.

Preferred:

Experience in utilization review, skilled nursing, home health, discharge planning, behavioral health, community resources, and/or other home and community-based agencies.

Skills

Required:

Excellent verbal and written communication skills; with effective charting practices.

Excellent organizational, time-management and priority-setting skills.

Strong clinical skills with a knowledge of care needs for elderly, disabled, and/or frail populations and has applied knowledge of End-of-Life care.

Customer Service Skills:  Provision of excellent customer service required due to frequent communication with providers, members and interdisciplinary team.

Technical Skills: Must be computer literate and proficient in Microsoft Office (Outlook, Word, Excel, PowerPoint, Teams).  Ability to effectively utilize computer and appropriate software and interacts as needed with L.A. Care Information System.

Ability to maintain strict member confidentiality and complies with all HIPAA requirements.

Preferred: 

Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

Required:
Travel to offsite locations for work.