Case Management - Nurse, Consultant
Company: Blue Shield of California
Location: Rancho Cordova
Posted on: May 8, 2024
Job Description:
Your Role
The Federal Employee Program (FEP) Care Management team performs
integrated case management (CM) and disease management (DM)
activities demonstrating clinical judgment and independent
analysis, collaborating with members and those involved with their
care including a multidisciplinary team and the member's treating
physicians. The Registered Nurse Case Management Lead will report
to the FEP Department Manager. In this role you will be responsible
for exhibiting BSC leadership behaviors while supporting the
overall FEP CM team as a subject matter expert.
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
-
- 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 -
- Support team through consistent and successful caseload
management and workload to achieve team goals, regulatory
timelines, and accreditation standards -
- Leads team huddles/ meetings to support process and
collaboration of team members
- Contributes to the adoption, evaluation and improvement of
electronic medical record (EMR). Participates in go-live testing
which may occur afterhours or on weekends, based on the posted
monthly release schedule
- Works to achieve operational targets with significant impact on
the departmental results with a concentration on system
enhancements to improve the documentation process for the
staff
- Contributes to the development of goals for the department and
planning efforts (budgets, operational plans, etc.). Influences the
performance of the business unit in achieving Blue Shield of
California's objectives. Responsible for collecting data required
for contractual reporting
- Responsible for auditing, providing guidance, coaching,
training and precepting to other employees within job area.
Collaborate with the training department and operation department
to customize training specific to the FEP team
- Issues faced are numerous and undefined, and require detailed
information gathering, analysis and investigation to understand the
problem
Your Knowledge and Experience
- Requires a current CA RN License
- Certified Case Manager (CCM) Certification or is in 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
- Demonstrated ability to test EMR systems and write acceptance
criteria statements
- Extensive knowledge of evidenced based clinical practice
guidelines particularly for chronic conditions
- Working knowledge of regulatory and accreditation standards
preferred (NCQA, Case Management Society of America CMSA)
- Knowledge of Coordination of Care, Medicare regulations, prior
authorization, level of care and length of stay criteria sets
desirable
- Demonstrated and evolving competence in CM functions and
standards of practice
- Demonstrated ability to independently assess, evaluate, and
interpret clinical information and care planning
- Excellent analytical and problem-solving skills.
- Strong clinical documentation skills, independent problem
identification and resolution skills. Proficiency with Microsoft
applications including Word, Excel, Outlook, and Teams
- Possesses cultural awareness to work effectively, respectfully,
and sensitively within the client's cultural context
- In depth understanding of community resources, treatment
options, home health, funding sources and special programs
- Work is performed with limited oversight
Pay Range:
The pay range for this role is: $ 109120.00 to $ 163680.00 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.
Keywords: Blue Shield of California, Rancho Cordova , Case Management - Nurse, Consultant, Healthcare , Rancho Cordova, California
Didn't find what you're looking for? Search again!
Loading more jobs...