Complex Care Management - Nurse (Registered Nurse)

Company: Blue Shield of CA
Location: Rancho Cordova
Posted on: May 16, 2020

Job Description:

At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. Were excited to share Blue Shield of California has received awards and recognition for LGBT diversity, quality improvement, most influential women in corporate America, Bay Areas top companies in volunteering & giving, and one of the worlds most ethical companies. Here at Blue Shield of California, were striving to make a positive change across our industry and the communities we live in Join us! GENERAL SUMMARY:

Complex Care Manager (CCM) is responsible for coordinating resources, researching appropriate cost-effective alternative/ options for the catastrophic, chronically ill, identified high-risk members on a case by case basis to achieve realistic healthcare outcomes. The primary goal of the CCM is to assist with optimizing member care across the healthcare continuum to decrease healthcare utilization and prevent avoidable emergency room visits and hospital admissions. The CCM is responsible for collaborating closely with the member and multi-disciplinary teams regarding the member condition(s) and developing a care plan that fits the needs of the member. The CCM provides appropriate member self management education on their specific healthcare needs. The CCM will complete both telephonic and in person communication with the member based on the members level of acuity.

ESSENTIAL FUNCTIONS AND KEY RESPONSIBILITIES:

* Communicate and collaborate with member and providers on care planning and healthcare needs to ensure person centered care planning and execution of care planning.

* Care plan and member healthcare assessment documentation based on NCQA Standards and Regulatory requirements.

* Communicate and collaborate with multidisciplinary team regarding member care plan and healthcare needs.

* Attend and present CCM cases at interdisciplinary care team (ICT) rounds.

GENERAL SUMMARY:

Complex Care Manager (CCM) is responsible for coordinating resources, researching appropriate cost-effective alternative/ options for the catastrophic, chronically ill, identified high-risk members on a case by case basis to achieve realistic healthcare outcomes. The primary goal of the CCM is to assist with optimizing member care across the healthcare continuum to decrease healthcare utilization and prevent avoidable emergency room visits and hospital admissions. The CCM is responsible for collaborating closely with the member and multi-disciplinary teams regarding the member condition(s) and developing a care plan that fits the needs of the member. The CCM provides appropriate member self management education on their specific healthcare needs. The CCM will complete both telephonic and in person communication with the member based on the members level of acuity.

ESSENTIAL FUNCTIONS AND KEY RESPONSIBILITIES:

* Communicate and collaborate with member and providers on care planning and healthcare needs to ensure person centered care planning and execution of care planning.

* Care plan and member healthcare assessment documentation based on NCQA Standards and Regulatory requirements.

* Communicate and collaborate with multidisciplinary team regarding member care plan and healthcare needs.

* Attend and present CCM cases at interdisciplinary care team (ICT) rounds.

MINIMUM AND PREFERRED QUALIFICATIONS:

* Typical education and experience required and preferred, including licensing requirements, special training and certifications.


EXPERIENCE:

* Minimum of two years experience in Case Management in a Managed Care environment and minimum three experiences in an acute care setting, Health Plan experience preferred

EDUCATION:

* Registered Nurse with a Bachelors Degree, Associates Degree will be considered with appropriate additional years of experience

LICENSE/CERTIFICATION/SPECIAL TRAINING:

* Active CA RN License in good standing.

* Certification in Case Management (CCM) preferred with ability to complete certification within 1 year of employment.

SKILLS/ABILITIES:

* Knowledge of Medicare, Medical and Cal-Medi Connect program regulations.

* Knowledge of NCQA Standards.

* Ability to navigate through complex healthcare systems in a fast pace environment.

* Ability to create member specific care plans based on their healthcare goals.

* Ability to speak Spanish is preferred.

MINIMUM AND PREFERRED QUALIFICATIONS:

* Typical education and experience required and preferred, including licensing requirements, special training and certifications.


EXPERIENCE:

* Minimum of two years experience in Case Management in a Managed Care environment and minimum three experiences in an acute care setting, Health Plan experience preferred

EDUCATION:

* Registered Nurse with a Bachelors Degree, Associates Degree will be considered with appropriate additional years of experience

LICENSE/CERTIFICATION/SPECIAL TRAINING:

* Active CA RN License in good standing.

* Certification in Case Management (CCM) preferred with ability to complete certification within 1 year of employment.

SKILLS/ABILITIES:

* Knowledge of Medicare, Medical and Cal-Medi Connect program regulations.

* Knowledge of NCQA Standards.

* Ability to navigate through complex healthcare systems in a fast pace environment.

* Ability to create member specific care plans based on their healthcare goals.

* Ability to speak Spanish is preferred.

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.

Keywords: Blue Shield of CA, Rancho Cordova , Complex Care Management - Nurse (Registered Nurse), Healthcare , Rancho Cordova, California