Medical Case Manager (High Risk Pregnancy)

Medical Case Manager (High Risk Pregnancy)

CalOptima

Join Us in this Amazing Opportunity

The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

More About the Opportunity

We are hoping you will join us as a Medical Case Manager (High Risk Pregnancy) and help shape the future of healthcare where you'll be an integral part of our Case Management team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for CalOptima Health's members. The Medical Case Manager, High-Risk Pregnancy, will facilitate communication and coordination among all participants of the health care team and the member to ensure that the services provided promote quality, cost-effective outcomes. You will be a resource for high-risk pregnancy members, delegated plan Case Managers, Personal Care Coordinators (PCCs) and community partners to address medical, behavior and psychosocial concerns. In conjunction with other team members, you will develop and make recommendations for a comprehensive individualized care plan at all levels of care. Together, we are building a stronger, more equitable health system.

Your Contributions To the Team:

• 95% - Case Management
  • Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.
  • Reviews and analyzes member health risk assessment (HRA) answers and uses clinical judgment to assign a care management level (CML).
  • Reviews Interdisciplinary Care Team (ICT) summaries and individual care plans (ICP) to ensure compliance with Centers for Medicare and Medicaid Services (CMS) and Model of Care requirements.
  • Works collaboratively with the PCCs to develop care plans for members, including those who are pregnant, using member HRA data.
  • Utilizes all other available data to formulate care plans in the absence of an HRA.
  • Ensures and facilitates communication between PCCs and delegated plan PCCs to achieve favorable member health outcomes.
  • Responds appropriately to case management triggers generated as part of the HRA or ICT process.
  • Anticipates needs for those at risk of transitioning of care and proactively support reducing the risk of re-entering a higher level of care.
  • Acts as an integral part of the team, providing verbal and written support of member needs.
  • Collaborates and communicates with the member, family, significant other(s), physicians, health network (HN) designee and other health care providers to support and accomplish goals identified on the individualized care plan in all care settings.
  • Accepts referrals for case management and serves as CalOptima Health's liaison to community agencies, organizations and state personnel.
  • Provides case management consultation and education to members, their families and the HNs.
  • Acts as an advocate to assist in the coordination of the client's identified psychosocial needs, utilizing community resources and support when appropriate.
  • Participates in proactive identification of patients appropriate for care management.
  • Initiates appropriate follow-up and the development of an individual care plan incorporating assessment, education, resource planning and coordination of services of those patients accepted for case management.
  • Assists, as requested, to collect and analyze data from initial/annual/updated health risk assessments, stratification tools, outcome measures and internal/external reports to identify trends, individual issues, problems and resources that are most appropriate to meet client's needs.
  • Develops and maintains a network of current community resources and services where members can be referred for assistance.
  • Performs regular review of cases and events to identify patterns/trends and to ensure the department's compliance with CMS, Department of Health Care Services (DHCS) and National Committee for Quality Assurance (NCQA) standards.
  • Maintains documentation of case management plans/interventions and statistics required to demonstrate activities of the ICT and the impact of case management, quality and care settings that best meet the member's needs.
  • Serves as a liaison and resource between CalOptima Health and the HNs departments, as applicable.
  • Develops and maintains a good working relationship with all areas.
    
    
• 5% - Other
  • Completes other projects and duties as assigned.

Do You Have What the Role Requires?

• Associate degree in nursing (ADN) or related field PLUS 3 years of clinical experience working with pregnancy and/or managed care experience required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

You'll Stand Out More If You Possess the Following:

• Bachelor of Science degree in Nursing (BSN), public health or a related field.
  
• Active and unrestricted Registered Nurse CCM certificate.
  
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).
  

What the Regulatory Agencies Need You to Possess?

• Current unrestricted Registered Nurse (RN) license to practice in the state of California required.

Your Knowledge & Abilities to Bring to this Role:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Your Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Ways We Are Here For You

• You'll enjoy competitive compensation for this role.
  • Our current hiring range is: Pay Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615).
    • The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.
      
      
• This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**)
  NOTE: Training will be held in the office for the first 4 weeks from 8:00am - 5:00pm, on Tuesdays and Thursdays.
• A comprehensive benefits package
• CalPERS pension program and additional retirement packages.
• Additional benefits and perks including:
  • A generous PTO program
  • A quality work life balance
  • Various wellness programs
  • Tuition Reimbursement
  • Professional development opportunities
  • Career development opportunities
  • Flexible scheduling
  • And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.

Our Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

Why Join Us?

We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.

What's Your Next Step?

All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is December 8, 2025 at 9:00 PM (PST). We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

Our Commitment to You

Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet.

We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process.

CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.


To apply, please visit: https://jobs.caloptima.org/jobs/medical-case-manager-high-risk-pregnancy-505-city-parkway-west-california-united-states







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