Case Manager

1 week ago

California, United States Blue Shield of California Full time

About the Role

The Blue Shield of California team is seeking a highly skilled Case Management Nurse, Senior to join our Children's Health Program (CHP) team. In this role, you will be responsible for managing member needs for specific CCS/EIES/DDS/CSHCN and other clinical programs and care coordination.

Key Responsibilities

  • Perform care management/care coordination for members using Blue Shield Medical Policies and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medi-Cal and CCS/EIES/DDS/ECM Eligibility guidelines.
  • Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance.
  • Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning.
  • Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
  • Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
  • Prepares and presents cases to Medical Director (MD) for medical director oversight and CCS eligibility determination.
  • Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
  • Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
  • Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate and provide care coordination to identified CHP members.
  • Provides referrals to Social Services, Behavioral Health, Appeals and Grievance, and Quality Departments as necessary. In addition to collaboration with County CCS and Regional Centers.

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