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Case Manager
2 months ago
About the Role
The Blue Shield of California team is seeking a skilled Case Management Nurse, Senior to join our Children's Health Program (CHP) team. As a key member of our team, you will be responsible for providing identification, referrals, and care management for all Medi-Cal members under the age of 21 and collaborating with our Promise Clinical Team.
Key Responsibilities
- Perform clinical review, assessment, and evaluation of medical services for the organization using established and approved Blue Shield Medical Policies and CCS/EIES/DDS/ECM Eligibility guidelines, which align with nationally recognized standards.
- Manage member needs for specific CCS/EIES/DDS/CSHCN and other clinical programs and care coordination.
- Assist in daily inventory, provide high-quality clinical reviews, perform efficient care management and care coordination, and ensure compliance with performance metrics.
- Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
- Ensure discharge planning at levels of care appropriate for the member's needs and acuity and determine post-acute needs of members, including levels of care, durable medical equipment, and post-service needs, to ensure quality and cost-appropriate discharge planning.
- Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members 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 intervene or as clinically appropriate.
- Provide care coordination to identified CHP members and refer to Social Services, Behavioral Health, Appeals and Grievance, and Quality Departments as necessary, in addition to collaboration with County CCS and Regional Centers.
Requirements
- Strong clinical knowledge and experience in case management and care coordination.
- Excellent communication and interpersonal skills.
- Ability to work in a fast-paced environment and prioritize multiple tasks and responsibilities.
- Strong analytical and problem-solving skills.
- Ability to maintain confidentiality and handle sensitive information.
