Blue Shield of CA
Case Management - Nurse, Senior (Regional / Oncology)
Blue Shield of CA, Los Angeles, California, United States, 90079
Your Role
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. The Regional Registered Nurse Case Manager will report to the FEP Care Management 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.
Your Work
In this role, you will:
Coordinate care for lower level of care such as Skilled Nursing Facility, Home Health, Home Infusion, Acute Rehab, Long-term Acute Care Hospital, Hospice, and other community programs as appropriate.Perform effective discharge planning and collaborate with the member's support system and health care professionals involved in the continuum of care.Provide disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma, and Coronary Artery Disease). Outreach to members with HEDIS Care Gaps to assist with closure.Apply detailed knowledge of FEP PPO and Blue Shield of California's established medical/departmental policies, clinical practice guidelines, community resources, contracting, and community care standards to each case.Research and design treatment/care plans to promote quality of care and cost-effective health care services based on medical necessity complying with the contract for each appropriate plan type.Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance department (AGD).Recognize the client's 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 plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes.Initiate and implement appropriate modifications in the plan of care to adapt to changes occurring over time and through various settings.Must 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 documentation.
Your Knowledge and ExperienceRequires a current 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 5 years of prior experience in nursing, healthcare, or related field.3+ years managed care experience preferred.Comprehensive knowledge of case management, discharge planning, utilization management, disease management, and community resources preferred.Behavioral health, oncology, or OB/NICU/pediatrics experience preferred.Strong electronic clinical documentation skills, independent problem identification, and resolution skills.Knowledge of coordination of care, prior authorization, level of care, and length of stay criteria sets desirable.Competent understanding of NCQA and federal regulatory requirements.Demonstrate leadership, project management, and program evaluation skills and ability to interact with all levels including senior management and influence decision-making.Demonstrates 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 care.Pay Range:The pay range for this role is: $87,230.00 to $130,900.00 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 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. The Regional Registered Nurse Case Manager will report to the FEP Care Management 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.
Your Work
In this role, you will:
Coordinate care for lower level of care such as Skilled Nursing Facility, Home Health, Home Infusion, Acute Rehab, Long-term Acute Care Hospital, Hospice, and other community programs as appropriate.Perform effective discharge planning and collaborate with the member's support system and health care professionals involved in the continuum of care.Provide disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma, and Coronary Artery Disease). Outreach to members with HEDIS Care Gaps to assist with closure.Apply detailed knowledge of FEP PPO and Blue Shield of California's established medical/departmental policies, clinical practice guidelines, community resources, contracting, and community care standards to each case.Research and design treatment/care plans to promote quality of care and cost-effective health care services based on medical necessity complying with the contract for each appropriate plan type.Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance department (AGD).Recognize the client's 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 plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes.Initiate and implement appropriate modifications in the plan of care to adapt to changes occurring over time and through various settings.Must 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 documentation.
Your Knowledge and ExperienceRequires a current 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 5 years of prior experience in nursing, healthcare, or related field.3+ years managed care experience preferred.Comprehensive knowledge of case management, discharge planning, utilization management, disease management, and community resources preferred.Behavioral health, oncology, or OB/NICU/pediatrics experience preferred.Strong electronic clinical documentation skills, independent problem identification, and resolution skills.Knowledge of coordination of care, prior authorization, level of care, and length of stay criteria sets desirable.Competent understanding of NCQA and federal regulatory requirements.Demonstrate leadership, project management, and program evaluation skills and ability to interact with all levels including senior management and influence decision-making.Demonstrates 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 care.Pay Range:The pay range for this role is: $87,230.00 to $130,900.00 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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