Behavioral Health Nurse Case Manager
1 day ago
The Behavioral Health Nurse Case Manager - Care Coordination Specialist will play a vital role in ensuring the highest level of care for our members. This position requires a current CA RN License, Certified Case Manager (CCM) Certification, and at least 5 years of prior experience in nursing, healthcare or related field.
Responsibilities- Coordinate care for Lower Level of Care services, such as Residential Treatment, Partial Hospitalization Program, Intensive Outpatient Program, other outpatient services, and community programs.
- 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.
- 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.
- 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.
- Perform effective discharge planning and collaborate with member support system and health care professionals involved in the continuum of care.
- Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease).
- Bachelor of Science in Nursing or advanced degree preferred.
- Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources.
- Able to operate PC-based software programs including proficiency in Word and Excel.
- Strong clinical documentation skills, independent problem identification and resolution skills.
- Competent understanding of NCQA and federal regulatory requirements.
- Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care.
The estimated salary for this role is between $87,230.00 and $130,900.00 annually, depending on location and experience.
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