Case Management - Behavioral Health Nurse

Your RoleThe Behavioral Health Registered Nurse Case Manager will report to the FEP Department Manager. In this role you will determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the member’s needs. The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians.Your WorkIn this role, you will:

Coordinates care for Lower Level of Care such as Residential Treatment, Partial Hospitalization Program, Intensive Outpatient Program, other outpatient services, and community programs as appropriateResearch 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 typeProvide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)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 teamDesign appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomesInitiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settingsApplies detailed knowledge of FEP PPO and Blue Shield of California's (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each casePerforms effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of careProvides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease)Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs related to behavioral healthMust be able to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentationYour 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 field3+ years managed care experience preferredBachelor of Science in Nursing or advanced degree preferredRequires relevant behavioral health experienceComprehensive knowledge of case management, discharge planning, utilization management, disease management and community resourcesAble to operate PC-based software programs including proficiency in Word and Excel.Strong clinical documentation skills, independent problem identification and resolution skillsStrong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skillsCompetent understanding of NCQA and federal regulatory requirementsKnowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirableDemonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of careDemonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making

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