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:
Coordinate care for lower level of care such Skilled Nursing Facility, Home Health, Home Infusion, Acute Rehab, Long-term Acute Care Hospital, Hospice, and other community program as appropriate
Perform effective discharge planning and collaborate with member's support system and health care professionals involved in the continuum of care
Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease).
Outreach to members with HEDIS Care Gaps to assist with closure
Apply detailed knowledge of FEP PPO and Blue Shield of California's established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case
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
Must be able to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentation
Your Knowledge and Experience
Bachelor's degree of Science in Nursing or advanced degree is preferred
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 3+ years managed care experience in inpatient, outpatient or managed care environment preferred
Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources preferred
Behavioral health, oncology, or OB/NICU/pediatrics experience preferred
Strong electronic clinical documentation skills, independent problem identification and resolution skills
Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable
Competent understanding of NCQA and federal regulatory requirements
Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making
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
Pay Range:
The pay range for this role is: $ 89100.00 to $ 133650.00 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.
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