Your 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

Your 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