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Case Management - Nurse, Senior

Company: Blue Shield of California
Location: Rancho Cordova
Posted on: June 13, 2022

Job Description:

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 truly 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 comprehensive approach to DE&I combines a focus on our people processes and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen. Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in - join us 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 Senior Care Manager will report to the Manager of Care Management. In this role you will ensure that services are provided based on standardized procedures including coordination of care with specialists, community resources. Care Managers perform a blended function of utilization management (UM) and care management (CM) activities demonstrating clinical judgement 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. Initiation of timely individualized care plans (ICP) based on health risk assessment (HRA) completion, participation in and documentation of interdisciplinary meetings (ICT), assisting in transitions of care across all ages. Determines appropriateness of referral for CM services, mental health, and social services. Provides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD). Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases. Manages member treatment in order to meet recommended length of stay. Ensures DC planning at levels of care appropriate for the members needs and acuity. Assessment: Assesses members health behaviors, cultural influences and clients belief/value system. Evaluates 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 promotes continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSC. Determines realistic goals and objectives and provides appropriate alternatives. Actively solicits client's involvement. Planning: Designs appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjusts plans or creates contingency plans as necessary. Assesses and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settings. Develops appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Recognizes need for contingency plans throughout the healthcare process. Develops and implements the plan of care based on accurate assessment of the member and current of proposed treatment. 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 5 years of prior experience in nursing, healthcare or related field A minimum of 1 year experience in inpatient, outpatient or managed care environment required Health insurance/managed care experience desired. Transitions of care experience desired Excellent communications skills 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. PDN-96813c77-a7e6-4e17-a9af-801f19f3a931

Keywords: Blue Shield of California, Rancho Cordova , Case Management - Nurse, Senior, Executive , Rancho Cordova, California

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