Case Management
4 weeks ago
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 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:
- Create education materials for the HEDIS Initiatives selected and educate current staff on HEDIS measures and how to close the HEDIS Care Gaps
- Analyze HEDIS data sets to identify members who need additional support and outreach to members to provide education and improve healthcare outcomes.
- Collaborate with quality department to determine and address gaps in care, make suggestions to Management if the HEDIS Gap Closure focus should be updated.
- Assist the FEP PPO Clinical team to meet the Blue Cross Blue Shield FEP Association requirements
- 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, and other community program as appropriate.
- Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease).
- Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs related to behavioral health.
- 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
- 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.
- HEDIS and/or Quality Improvement experience preferred.
- 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.
Pay Range:
The pay range for this role is: $ 87230.00 to $ 130900.00 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.
-
Case Manager
4 days ago
El Dorado, United States Mainstream Nonprofit Solutions Full timeJob Type Full-time Description ****Average hourly rate is $24.88 (including wage, incentives, bonuses, overtime, shift differential, etc.)*******This position has hybrid capabilities for those that live in or around the El Dorado area. ***Do you like working with children and families? Then TFI Family Services has the job for you! We are looking for a...
-
Case Manager
3 weeks ago
El Dorado, United States Mainstream Nonprofit Solutions Full timeJob Type Full-time Description ****Average hourly rate is $24.88 (including wage, incentives, bonuses, overtime, shift differential, etc.)*******This position has hybrid capabilities for those that live in or around the El Dorado area. ***Do you like working with children and families? Then TFI Family Services has the job for you! We are looking for a...
-
Case Manager
5 days ago
El Dorado, United States The Salvation Army USA Central Territory Full timeJob Objective: Coordinate social services activities for the corps. Provide direct assistance and/or referral to clients in need based on established criteria; assess all families with minor children for eligibility in the Pathway of Hope (POH) program. Deliver all POH services using the strength-based case management model to families with a desire to take...
-
Case Manager
5 days ago
El Dorado, United States The Salvation Army USA Central Territory Full timeJob Objective: Coordinate social services activities for the corps. Provide direct assistance and/or referral to clients in need based on established criteria; assess all families with minor children for eligibility in the Pathway of Hope (POH) program. Deliver all POH services using the strength-based case management model to families with a desire to take...
-
Case Management
1 week ago
El Dorado Hills, United States Blue Shield of California Careers Full timeYour RoleThe 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...
-
Case Management
1 week ago
El Dorado Hills, United States Blue Shield of California Full timeYour 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...
-
Case Management
1 week ago
El Dorado Hills, United States Blue Shield of California Careers Full timeYour 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...
-
Travel Nurse RN
2 days ago
El Paso, TX, United States TotalMed Case Management Staffing Full timeTotalMed Case Management Staffing is seeking a travel nurse RN Case Management for a travel nursing job in El Paso, Texas. Job Description & Requirements Specialty: Case Management Discipline: RN Start Date: 06/10/2024 Duration: 13 weeks 40 hours per week Shift: 8 hours, days Employment Type: Travel We are seeking a Case Manager-Registered Nurse...
-
Case Manager RN or SW
4 days ago
El Dorado, United States South Arkansas Regional Hospital Full timePosition SummaryResponsible for the implementation of the Case Management process. Monitors physician documentation and works closely with the medical staff for appropriateness of hospitalization. Identifies and evaluates quality of care, infection control, safety hazards, potential risk management and utilization problems. Reports findings to Director for...
-
Case Management
1 week ago
El Dorado Hills, California, 95762, El Dorado County, CA, United States Blue Shield of California Full timeYour 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...
-
Case Management
1 week ago
United States, CA, El Dorado Hills Blue Shield of California Full timeYour 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...
-
Case Manager
2 weeks ago
Beverly Hills, United States Direct Counsel, LLC Full timeDirect Counsel is seeking two Bilingual Case Managers to join a boutique law firm located in Los Angeles, CA. As a Case Manager you must be highly organized and able to work on a varied caseload. The Case Manager will assist the attorney in developing settlements, preparing documents and correspondence as needed. The ideal candidate is customer focused and...
-
Case Manager
2 months ago
Beverly Hills, United States Direct Counsel, LLC Full timeJob DescriptionJob DescriptionDirect Counsel is seeking two Bilingual Case Managers to join a boutique law firm located in Los Angeles, CA. As a Case Manager you must be highly organized and able to work on a varied caseload. The Case Manager will assist the attorney in developing settlements, preparing documents and correspondence as needed. The ideal...
-
Registered Nurse
2 days ago
El Paso, TX, United States TotalMed Case Management Staffing Full timeTotalMed Case Management Staffing is seeking a travel nurse RN Case Management for a travel nursing job in El Paso, Texas. Specialty: Case Management ~ Shift: 8 hours, days ~ Employment Type: Travel TotalMed Case Management Staffing Job ID #1512484. Pay package is based on 8 hour shifts and 40 hours per week (subject to confirmation) with tax-free...
-
Case Manager
3 days ago
Forest Hills, United States FOREST HILLS COMMUNITY HOUSE Full timeJob DescriptionJob DescriptionCase Manager, Case Management Program Are you passionate about reaching new heights, teamwork, and making a meaningful contribution? Queens Community House (QCH) is a multi-site nonprofit organization serving the diverse population of Queens through a broad network of programs for children and youth, adults and families, and...
-
Case Manager
5 days ago
Forest Hills, United States Forest Hills Community House Full timeCase Manager, Case Management Program Are you passionate about reaching new heights, teamwork, and making a meaningful contribution? Queens Community House (QCH) is a multi-site nonprofit organization serving the diverse population of Queens through a broad network of programs for children and youth, adults and families, and older adults. Our mission is to...
-
Human Resources Manager
3 days ago
El Dorado Hills, United States Serrano Country Club Full time**JOB TITLE: HUMAN RESOURCES MANAGER** **DEPARTMENT: ADMINISTRATION** **REPORTS TO: DIRECTOR OF FINANCE** **FLSA STATUS: EXEMPT** **SUMMARY**: Assist club's management staff with the recruitment, selection and orientation of new staff members. Administer payroll records and ensure that all applicable federal, state, and local wage and hour, worker's...
-
Health Coach, Experienced
4 days ago
El Dorado Hills, United States Blue Shield of California Full timeThe Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities in collaboration with members and those involved with members care including registered nurse case managers, social workers, diet Health, Coach, Registered Nurse, Experience, Case Manager, Social Worker, Insurance, Healthcare
-
Scheduler/Administrative Assistant
3 days ago
El Dorado Hills, United States Frontier Dental Laboratories, Inc. Full timeJob DescriptionJob DescriptionDescription:SchedulerThe primary function of the Scheduler is providing exceptional customer service, answering phone calls, initiating phone calls with our Doctors and Staff, scheduling all new incoming cases, re-scheduling cases throughout the lab, Coordinating and scheduling outsourcing cases and ensuring that all cases are...
-
Health Coach, Experienced
5 days ago
El Dorado Hills, United States Blue Cross and Blue Shield Association Full timeYour Role The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities in collaboration with members and those involved with members' care including registered nurse case managers, social workers, dietitians, health coaches, pharmacists, and physicians. The FEP Health Coach will report to the FEP...