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Case Manager
1 month ago
Blue Shield of California is seeking a skilled Case Manager to join our team. As a key member of our Federal Employee Program (FEP) team, you will play a critical role in determining, developing, and implementing plans of care for our members.
Key Responsibilities- Coordinate care for members requiring lower levels of care, including residential treatment, partial hospitalization programs, and community programs.
- Design and implement treatment plans that promote quality care and cost-effective health services, ensuring compliance with contractual requirements.
- Provide referrals to Quality Management, Disease Management, and Appeals and Grievance departments as needed.
- Recognize and respect members' autonomy in making informed choices about their care.
- Develop and implement plans of care that enhance quality, access, and cost-effective outcomes.
- Initiate and implement modifications to plans of care as needed to adapt to changes in members' conditions or care settings.
- Apply detailed knowledge of FEP PPO and Blue Shield of California's policies, clinical practice guidelines, community resources, and contracting standards to each case.
- Collaborate with members, healthcare professionals, and support systems to ensure effective discharge planning and continuum of care.
- Provide disease management education on core chronic conditions, including diabetes, heart failure, COPD, asthma, and coronary artery disease.
- Current CA RN License
- Certified Case Manager (CCM) Certification or in process of completing certification
- At least 5 years of prior experience in nursing, healthcare, or a related field
- 3+ years of managed care experience preferred
- Bachelor of Science in Nursing or advanced degree preferred
- Relevant behavioral health experience
- Comprehensive knowledge of case management, discharge planning, utilization management, disease management, and community resources
- 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
- Demonstrate leadership, project management, and program evaluation skills and ability to interact with all levels including senior management and influence decision-making
The pay range for this role is: $ 87230.00 to $ 130900.00 for California.
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.
