Case Management - Nurse, Senior

Case Management - Nurse, Senior

The Case Manager will report to the Manager of Case Management and is responsible for the coordination of care and services on behalf of Members of Blue Shield of California. The Case Manager effectively collaborates directly with the Member, Member's Family, and Interdisciplinary Care Team to achieve consensus and promote positive Member health outcomes through the assessment, planning, implementation, and evaluation of the Members Care Plan. The Case Manager identifies gaps in care and coordinates the available resources required to meet the Member's health care needs through clear communication and advocacy that aims to promote quality cost-effective interventions based on medical necessity and compliance with the Members Health Plan.

Your Work

In this role, you will:

• Research and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying withthe contract for each appropriate plan type.
• Collaborate with the interdisciplinary healthcare team to help reduce hospital re-admissions and ensure members receive timely preventive care and screening tests.
• Coordinates care for specific high risk patient population, including referrals to community resources, facilitation of medical services, referral to ancillary providers, etc.
• Recognize the clients right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
• Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes.
• Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings
• Strong written and verbal communication skills with ability to advocate and negotiate on behalf of the Member. Bilingual preferred.
• Strong clinical documentation skills, independent problem identification and resolution skills.
• Ability to work with minimal supervision within the company and with external partners and demonstrate professional judgment and critical thinking when advocating for medical necessity that promotes quality, cost-effective care.
• Demonstrates cultural competence and understanding and respect for the beliefs, value systems, and decisions of the Member.
• Understanding of the Members right to self-determination as it relates to the ethical principle of autonomy.
• Proficient in software programs including Microsoft Office (Word/Outlook/Excel).

Your Knowledge and Experience

• Requires a current CA RN License
• Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
• Requires at least 5 years of prior experience in nursing, healthcare or related field
• Experience in collaborating with Medical Groups and Independent Physician Associations and working with the Medicare population preferred.
• Demonstrated competence in Case Management in accordance with CMSA Standards of Practice for Case Management.
• Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
• Ability to research community resources, treatment options, home health, funding sources and special programs.
• Knowledge of evidenced based clinical practice guidelines particularly for chronic conditions.
• Understanding of the different levels of care and Transitions of Care (TOC).
• Knowledge on Prior Authorization Process and Utilization Management Process desirable.
• Knowledge of regulatory/accreditation standards desirable (NCQA, DMHC, CMSA).

Pay Range:
The pay range for this role is: $ 85360.00 to $ 128040.00 for California.

Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.