Senior Case Manager
3 weeks ago
Job Summary
This role is part of the Care Management team at Blue Shield of California, supporting the mission of providing support to patients in maintaining health and wellness in the outpatient setting. As a Senior Care Manager, you will ensure that services are provided based on standardized procedures, including coordination of care with specialists, community resources, and healthcare professionals.
Your Responsibilities
- Develop and implement individualized care plans to promote quality of care and cost-effective health services based on medical necessity and contract requirements.
- Initiate timely care plans based on health risk assessments, participation in interdisciplinary meetings, and documentation of transitions of care.
- Determine the appropriateness of referrals for case management services, mental health, and social services.
- Provide referrals to Quality Management, Disease Management, and Appeals and Grievance departments.
- Conduct member care reviews with medical groups or individual providers for continuity of care, out-of-area/out-of-network, and investigational/experimental cases.
- Manage member treatment to meet recommended length of stay and ensure discharge planning at appropriate levels of care.
- Assess members' health behaviors, cultural influences, and belief systems, and evaluate information related to current/proposed treatment plans.
- Research opportunities for improvement in assessment methodology and promote continuous improvement.
- Determine realistic goals and objectives, provide appropriate alternatives, and actively solicit clients' involvement.
Requirements
- Current CA RN License
- Bachelor's of Science in Nursing or advanced degree preferred
- Certified Case Manager (CCM) Certification or in process of completing certification
- At least 5 years of prior experience in nursing, healthcare, or related field
- A minimum of 1 year experience in inpatient, outpatient, or managed care environment
- Health insurance/managed care experience desired
- Transitions of care experience desired
- Excellent communication skills
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