Blue Shield of California
Case Management - Nurse, Senior
Blue Shield of California, Woodland Hills, California, us, 91371
Case Management - Nurse, Senior at Blue Shield of California summary:
The Senior Case Management Nurse is responsible for providing support to patients in the outpatient setting, facilitating their health and wellness. This role involves developing individualized care plans, coordinating care with specialists, and ensuring compliance with medical necessity and clinical guidelines. The position requires strong clinical judgement, effective communication skills, and experience in both inpatient and outpatient care environments.
Your Role
The 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 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 with contract for each appropriate plan type.
Initiation 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 ages.
Determines appropriateness of referral for CM services, mental health, and social services.
Provides 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 cases.
Manages member treatment in order to meet recommended length of stay. Ensures DC planning at levels of care appropriate for the members needs and acuity.
Assessment: 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 barriers.
Research 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 BSC.
Determines realistic goals and objectives and provides appropriate alternatives. Actively solicits client’s involvement.
Planning: 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 necessary.
Assesses 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 settings.
Develops appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
Recognizes need for contingency plans throughout the healthcare process.
Develops and implements the plan of care based on accurate assessment of the member and current of proposed treatment.
Your Knowledge and Experience Current CA RN License. Bachelors of Science in Nursing or advanced degree preferred. 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 A minimum of 3 years experience in inpatient, outpatient or managed care environment required Health insurance/managed care experience desired. Transitions of care experience desired Excellent 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-RU1
Keywords: case management, nursing, patient care, healthcare coordinator, health plans, clinical judgment, utilization management, care plans, transitions of care, cost-effective care
Your Role
The 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 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 with contract for each appropriate plan type.
Initiation 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 ages.
Determines appropriateness of referral for CM services, mental health, and social services.
Provides 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 cases.
Manages member treatment in order to meet recommended length of stay. Ensures DC planning at levels of care appropriate for the members needs and acuity.
Assessment: 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 barriers.
Research 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 BSC.
Determines realistic goals and objectives and provides appropriate alternatives. Actively solicits client’s involvement.
Planning: 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 necessary.
Assesses 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 settings.
Develops appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
Recognizes need for contingency plans throughout the healthcare process.
Develops and implements the plan of care based on accurate assessment of the member and current of proposed treatment.
Your Knowledge and Experience Current CA RN License. Bachelors of Science in Nursing or advanced degree preferred. 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 A minimum of 3 years experience in inpatient, outpatient or managed care environment required Health insurance/managed care experience desired. Transitions of care experience desired Excellent 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-RU1
Keywords: case management, nursing, patient care, healthcare coordinator, health plans, clinical judgment, utilization management, care plans, transitions of care, cost-effective care