Posted in Other 30+ days ago.
Type: Full Time
Overview:
Care Managers perform 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. Care Managers determine, develop and implement a plan of care based on accurate and comprehensive assessment of the member's needs. Care Managers apply detailed knowledge of Blue Shield of California (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.
Responsibilities:
- Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs.
- 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.
- Works with complex cases, promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits.
- Provides guidance to the provider network.
- 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, Residential Treatment Center, Home Health, Home Infusion, Rehab
- Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease).
- Makes referrals to Quality Management, Catastrophic Case Management and Appeals and Grievance Department.
Additional Skills:
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Able to operate PC-based software programs including proficiency in Word and Excel.
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Strong clinical documentation skills, independent problem identification and resolution skills.
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Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills.
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Competent understanding of NCQA and federal regulatory requirements.
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Knowledge of Coordination of Care, prior authorization, level of care and length of stay criteria sets desirable.
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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.
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Solid case preparation
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Demonstrated leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making.
- Bachelor' s of Science in Nursing or advanced degree preferred.
- Active California RN license required.
- Must have specialty training in: case management and behavioral health nursing,
- Five years experience in case management, utilization management, post service review, quality management or health plan/IPA management.
- Case Management, Quality or other equivalent certification that is related to the specific area to be managed is required.
- Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources.
- Strong supervisory, communication and negotiation skills.
- Able to operate PC-based software programs including proficiency in Word and Excel.
Additional Information
- Our Company: 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. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!
- Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
- Equal Employment Opportunity: 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.
- Requisition ID: 20002HA
- Posting Date: Nov 20, 2020
- Schedule: Full-time
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