Production Operator

801 Gateway Blvd, South San Francisco, CA 94080, USA ● Virtual Req #138

Monday, March 31, 2025

General Description

HPSM seeks a dedicated Senior Care Manager to collaborate with members and their care teams in assessing, developing, and managing personalized care plans that drive optimal health outcomes for individuals with complex medical and psychosocial needs. This role integrates evidence-based clinical guidelines to enhance the quality and efficiency of care delivery for health plan members. As a clinical subject matter expert, the Senior Care Manager will provide consultation and support to fellow care managers on complex cases while also contributing to the development and advancement of the Integrated Care Management (ICM) model.

Qualifications

The following represents the typical way to achieve the necessary skills, knowledge and ability to qualify for this position:

Education and Experience

• Bachelor’s degree in nursing or master’s degree in social work.
• Three (3) years clinical case management experience in a medical or behavioral health field.

Skills

• Bilingual skills (Spanish, Tagalog or Chinese) highly preferred.
• Communicate effectively, both verbally and in writing.
• Work cooperatively with others.

Knowledge

• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
• Case management principles and practices.
• Medicare and Medi-Cal programs and benefits.
• Community resources.
• The complexities of working with dually eligible populations.

Abilities

• Work as part of a team and support team decisions.
• Adapt to changes in requirements/priorities for daily and specialized tasks.
• Work efficiently with people in varying positions.
• Gain consensus on resolution of problems.
• Work independently, with limited supervision; problem solve independently.

Licensure/Certifications

• Valid California license as a Registered Nurse (RN), or Licensed Clinical Social Worker (LCSW) is required.
• Certification as Certified Case Manager (CCM) or other clinical certifications preferred.

Duties & Responsibilities

Essential Functions

Role 1: Care Coordination and Case Management

• Manage a panel of assigned members, conducting comprehensive assessments to identify physical, psychosocial, environmental, safety, and developmental needs.
• Develop and implement individualized care plans in collaboration with members, their authorized representatives, primary care providers, and other care team members.
• Utilize risk stratification and evidence-based clinical guidelines to implement case management interventions that optimize health outcomes.
• Coordinate care with community resources and interdisciplinary teams to prevent service duplication and ensure seamless care transitions.
• Facilitate referrals to HPSM departments, community-based organizations, and government agencies as needed.

Role 2: Member Support and Advocacy

• Provide ongoing support to members throughout their healthcare journey by collaborating with internal departments such as Inpatient and Outpatient Utilization Management (UM) and Pharmacy.
• Identify members with complex medical and behavioral health needs, ensuring the completion of assessments and development of member-centric care plans.
• Engage in interdisciplinary team (IDT) meetings and clinical huddles to monitor service delivery and ensure alignment with member needs.
• Educate members, caregivers, and other stakeholders on interventions, resources, benefits, and medication effects to enhance self-management.
• Promote clear communication among care teams and treating providers by ensuring alignment on care plans and service coordination.

Role 3: Compliance and Documentation

• Document all member interactions, provider communications, and IDT meetings in the electronic medical record (EMR) within 48 hours.
• Assist with internal and external audits, National Committee for Quality Assurance (NCQA) requirements, and other compliance-related tasks.
• Ensure adherence to regulatory and organizational policies while supporting department-wide process improvements and program expansion initiatives.
• Monitor and maintain high-quality care management practices through continuous quality improvement efforts.

Role 4: Departmental Support and Collaboration

• Provide coverage for staff during planned and unplanned absences and offer cross-coverage across other care management tiers.
• Support departmental operations, including participation in special projects and assignments.
• Assist leadership with process improvement initiatives to enhance program efficiency and effectiveness.
• Act as a clinical subject matter expert and provide consultation on complex cases to other care managers.

Secondary Functions

• Maintain a valid California license as a Registered Nurse (RN), or Licensed Clinical Social Worker (LCSW).
• Adhere to work performance norms and attendance expectations.