Blue Shield of CA
Case Management - Nurse, Consultant
Blue Shield of CA, San Diego, California, United States, 92189
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 Nurse Consultant will report to the Manager of Care Management for the Population Health Management Medi-Cal Team. In this role, you will ensure that services are provided based on standardized procedures including coordination of care with specialists and community resources. Care Managers perform a blended function of utilization management (UM) and care management (CM) activities demonstrating clinical judgment 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.Initiate timely individualized care plans (ICP) based on applicable assessments and assist in transitions of care across all ages.Determine appropriateness of referral for CM services, mental health, and social services.Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance department (AGD).Conduct member care review with medical groups or individual providers for continuity of care, out of area/out of network, and investigational/experimental cases.Assess members' health behaviors, cultural influences, and clients' belief/value systems. Evaluate all information related to current/proposed treatment plans and in accordance with clinical practice guidelines to identify potential barriers.Research opportunities for improvement in assessment methodology and actively promote continuous improvement. Anticipate potential barriers while establishing realistic goals to ensure success for the member, providers, and BSC.Determine realistic goals and objectives and provide appropriate alternatives. Actively solicit client's involvement.Design appropriate and fiscally responsible plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjust plans or create contingency plans as necessary.Assess and re-evaluate health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiate and implement appropriate modifications in the plan of care to adapt to changes occurring over time and through various settings.Develop appropriate and fiscally responsible plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes.Recognize the need for contingency plans throughout the healthcare process.Develop and implement the plan of care based on accurate assessment of the member and current or proposed treatment.Assume supervisor day-to-day responsibilities in manager's absence and under the direction of the manager.Analyze productivity and internal reports to ensure compliance.Collaborate with department leadership to identify program development opportunities.Mentor case managers with complex cases to promote quality of care, cost-effective health care services based on medical necessity and comply with contract for each appropriate plan type.Perform precepting for new hires or those who are not meeting expectations.Participate in special projects as needed.
Your Knowledge and ExperienceCurrent CA RN License. Bachelor of Science in Nursing or advanced degree preferred.Certified Case Manager (CCM) Certification or is in the process of completing certification when eligible based on CCM application requirements.Requires at least 7 years of prior experience in nursing, healthcare, or related field.A minimum of 3+ years of experience in inpatient, outpatient, or managed care environments required.Health insurance/managed care experience desired.Transitions of care experience desired.Excellent communication skills.Pay Range:The pay range for this role is: $109,120.00 to $163,680.00 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.
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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 Nurse Consultant will report to the Manager of Care Management for the Population Health Management Medi-Cal Team. In this role, you will ensure that services are provided based on standardized procedures including coordination of care with specialists and community resources. Care Managers perform a blended function of utilization management (UM) and care management (CM) activities demonstrating clinical judgment 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.Initiate timely individualized care plans (ICP) based on applicable assessments and assist in transitions of care across all ages.Determine appropriateness of referral for CM services, mental health, and social services.Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance department (AGD).Conduct member care review with medical groups or individual providers for continuity of care, out of area/out of network, and investigational/experimental cases.Assess members' health behaviors, cultural influences, and clients' belief/value systems. Evaluate all information related to current/proposed treatment plans and in accordance with clinical practice guidelines to identify potential barriers.Research opportunities for improvement in assessment methodology and actively promote continuous improvement. Anticipate potential barriers while establishing realistic goals to ensure success for the member, providers, and BSC.Determine realistic goals and objectives and provide appropriate alternatives. Actively solicit client's involvement.Design appropriate and fiscally responsible plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjust plans or create contingency plans as necessary.Assess and re-evaluate health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiate and implement appropriate modifications in the plan of care to adapt to changes occurring over time and through various settings.Develop appropriate and fiscally responsible plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes.Recognize the need for contingency plans throughout the healthcare process.Develop and implement the plan of care based on accurate assessment of the member and current or proposed treatment.Assume supervisor day-to-day responsibilities in manager's absence and under the direction of the manager.Analyze productivity and internal reports to ensure compliance.Collaborate with department leadership to identify program development opportunities.Mentor case managers with complex cases to promote quality of care, cost-effective health care services based on medical necessity and comply with contract for each appropriate plan type.Perform precepting for new hires or those who are not meeting expectations.Participate in special projects as needed.
Your Knowledge and ExperienceCurrent CA RN License. Bachelor of Science in Nursing or advanced degree preferred.Certified Case Manager (CCM) Certification or is in the process of completing certification when eligible based on CCM application requirements.Requires at least 7 years of prior experience in nursing, healthcare, or related field.A minimum of 3+ years of experience in inpatient, outpatient, or managed care environments required.Health insurance/managed care experience desired.Transitions of care experience desired.Excellent communication skills.Pay Range:The pay range for this role is: $109,120.00 to $163,680.00 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.
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