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Case Management - Nurse, Senior

Company: Blue Shield of California
Location: Rancho Cordova
Posted on: September 18, 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 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 Registered Nurse Case Manager will report to the FEP Department Manager. In this role you will be Care Managers 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: 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 Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings Applies detailed knowledge of FEP PPO and Blue Shield of California's (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case. Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care. Coordinates Care for Lower Level of Care coordination such as Skilled Nursing Facility, Home Health, Home Infusion, Rehab. Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease). 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 Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources. Able to operate PC-based software programs including proficiency in Word and Excel. Strong clinical documentation skills, independent problem identification and resolution skills. Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills. Competent understanding of NCQA and federal regulatory requirements. Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable. 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. Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making. 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-97445e56-4e97-4058-922c-602e1f10878f

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

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