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Case Manager

1 month ago

Rancho Cordova, California, United States Blue Shield of California Full time
Job Summary

We are seeking a highly skilled and experienced Case Manager to join our team at Blue Shield of California. As a Case Manager, you will play a critical role in coordinating care for our members, ensuring they receive the highest quality of care while minimizing costs.

Key Responsibilities
  • Coordinate care for members, including Skilled Nursing Facility, Home Health, Home Infusion, Acute Rehab, Long-term Acute Care Hospital, Hospice, and other community programs as appropriate.
  • Perform effective discharge planning and collaborate with members' support systems and healthcare professionals involved in the continuum of care.
  • Provide disease management education on core chronic conditions, including Diabetes, Heart Failure, COPD, Asthma, and Coronary Artery Disease.
  • 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 and cost-effective healthcare 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 members' rights to self-determination, including autonomy, and make informed choices that may not promote the best outcomes, as determined by the healthcare team.
  • Design appropriate and fiscally responsible plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
  • Initiate and implement appropriate modifications in plans of care to adapt to changes occurring over time and through various settings.
Requirements
  • Current CA RN License.
  • Certified Case Manager (CCM) Certification or in process of completing certification when eligible based on CCM application requirements.
  • At least 5 years of prior experience in nursing, healthcare, or related field.
  • 3+ years managed care experience 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.
  • Demonstrate professional judgment and critical thinking to promote the delivery of quality, cost-effective care, based on medical necessity, including intensity of service and severity of illness within contracted benefits and appropriate level of care.
What We Offer

We offer a competitive salary range of $ to $ for California, as well as opportunities for professional growth and development. If you are a motivated and experienced healthcare professional looking for a new challenge, we encourage you to apply for this exciting opportunity.