Blue Shield of California
Case Management - Nurse, Senior
Blue Shield of California, Long Beach, California, us, 90899
Your RoleThe Care Management team will serve to support the mission of the department, which is to provide support to patients in maintaining health and wellness in the outpatient setting. The Senior Care Manager will report to the Manager of Care Management. In this role you will ensure that services are provided based on standardized procedures including coordination of care with specialists, community resources. Care Managers perform a blended function of utilization management (UM) and care management (CM) activities demonstrating clinical judgement and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians.Your WorkIn 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 with contract for each appropriate plan typeInitiation of timely individualized care plans (ICP) based on health risk assessment (HRA) completion, participation in and documentation of interdisciplinary meetings (ICT), assisting in transitions of care across all agesDetermines appropriateness of referral for CM services, mental health, and social servicesProvides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental casesManages member treatment in order to meet recommended length of stay. Ensures DC planning at levels of care appropriate for the members needs and acuityAssessment: Assesses members health behaviors, cultural influences and clients belief/value system. Evaluates all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriersResearch opportunities for improvement in assessment methodology and actively promotes continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSCDetermines realistic goals and objectives and provides appropriate alternatives. Actively solicits client’s involvementPlanning: Designs appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjusts plans or creates contingency plans as necessaryAssesses and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settingsDevelops appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomesRecognizes need for contingency plans throughout the healthcare processDevelops and implements the plan of care based on accurate assessment of the member and current of proposed treatmentYour Knowledge and Experience
Requires a current CA RN LicenseCertified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirementsRequires at least 5 years of prior experience in nursing, healthcare or related fieldA minimum of 3+ years managed care experience in inpatient, outpatient or managed care environment preferredHealth insurance/managed care experience preferredTransitions of care experience preferredExcellent communications skills
Pay Range:The pay range for this role is: $ 87230.00 to $ 130900.00 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.#LI-MM4
Research and design treatment /care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan typeInitiation of timely individualized care plans (ICP) based on health risk assessment (HRA) completion, participation in and documentation of interdisciplinary meetings (ICT), assisting in transitions of care across all agesDetermines appropriateness of referral for CM services, mental health, and social servicesProvides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental casesManages member treatment in order to meet recommended length of stay. Ensures DC planning at levels of care appropriate for the members needs and acuityAssessment: Assesses members health behaviors, cultural influences and clients belief/value system. Evaluates all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriersResearch opportunities for improvement in assessment methodology and actively promotes continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSCDetermines realistic goals and objectives and provides appropriate alternatives. Actively solicits client’s involvementPlanning: Designs appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjusts plans or creates contingency plans as necessaryAssesses and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settingsDevelops appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomesRecognizes need for contingency plans throughout the healthcare processDevelops and implements the plan of care based on accurate assessment of the member and current of proposed treatmentYour Knowledge and Experience
Requires a current CA RN LicenseCertified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirementsRequires at least 5 years of prior experience in nursing, healthcare or related fieldA minimum of 3+ years managed care experience in inpatient, outpatient or managed care environment preferredHealth insurance/managed care experience preferredTransitions of care experience preferredExcellent communications skills
Pay Range:The pay range for this role is: $ 87230.00 to $ 130900.00 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.#LI-MM4