Job DescriptionYour Role The Case Management team performs case management (CM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating MDs. The Case Management Nurse, Senior will report to the Sr Manager, Care Management- Behavioral Health. In this role, you will determine, develop, and implement the plan of care based on accurate assessment of the member and current or proposed treatment plan in cases of member inquiry, triage hub, Behavioral Health condition, chronic conditions, poly-pharmacy, and inpatient discharge planning. Your Work In this role, you will:
- Research and design treatment/care plans to promote quality of care, cost effective healthcare 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 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 team
- Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes
- Evaluate 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 promote continuous improvement
- Anticipate potential barriers while establishing realistic goals to ensure success for the member, providers, and BSC
- 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 system
- 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 plan of care to adapt to changes occurring over time and through various settings
- Develop appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes
QualificationsYour Knowledge and Experience
- Requires a current CA RN License
- Requires current Certified Case Manager (CCM) certification or is in process of completing certification when eligible based on CCM application requirements
- Requires 5 years of experience in nursing, healthcare, or related field
- Managed care experience of at least 3 years is preferred
- Bachelor's degree of Science in Nursing or advanced degree is preferred
- Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning is preferred
- Extensive knowledge of evidenced based clinical practice guidelines particularly for chronic conditions is preferred
- Ability to incorporate professional judgment and critical thinking when determining medical necessity that promotes quality, cost-effective care is preferred
- Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care, and length of stay criteria is preferred
- Ability to operate PC-based software programs including proficiency in Microsoft Office 365 applications including Word, Excel, Outlook, and Teams is preferred
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. #LI-JS3 About the Team Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen. Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!
Our Values: - Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
- Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
- Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model: Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That's why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work. Two ways of working: Hybrid (our default) and office
- Hybrid - In a business unit approved office a few times per year to 3 days per week, on average
- Office - In a business unit approved office 4+ days a week, on average. If the role you're applying for is deemed an Essential Role, the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.
Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. Please click here for further physical requirement detail.
Equal Employment Opportunity: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.