CenCal Health

Manager

• Manage a caseload of Dual Eligible Special Needs Plan (D-SNP) members with complex medical, behavioral health, functional, and psychosocial needs
• Conduct comprehensive medical, behavioral, functional, psychosocial, and social-determinants-of-health assessments
• Complete timely Health Risk Assessments and triage members according to clinical need and risk
• Develop, implement, monitor, and update individualized, person-centered care plans
• Coordinate integrated and interdisciplinary care with members, families, caregivers, providers, community organizations, transportation services, and internal departments
• Conduct and participate in care conferences, Interdisciplinary Care Team meetings, case reviews, rounds, and case presentations
• Address barriers to care, reduce avoidable hospitalizations and emergency-room visits, and promote optimal health outcomes
• Educate members and caregivers about benefits, community services, chronic-disease self-management, preventive health, medication adherence, and healthcare resources
• Coordinate transitions of care and safe discharges from hospitals, skilled nursing facilities, and other settings
• Document assessments, care plans, interventions, interactions, and progress notes accurately and timely
• Identify gaps in care and support quality-improvement initiatives, audits, data collection, and regulatory compliance
• Protect member confidentiality and comply with HIPAA, privacy regulations, and organizational policies
• Serve as a clinical resource and advocate for high-risk members

D-SNP Care Manager, RN