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Care Manager
2 months ago
As a Senior Care Manager at Blue Shield of California, you will play a critical role in supporting the mission of our department, which is to provide exceptional care and support to our patients in maintaining health and wellness in the outpatient setting.
Key Responsibilities- Develop and Implement Care Plans: Research and design treatment/care plans to promote quality of care and cost-effective healthcare services based on medical necessity, complying with contracts for each appropriate plan type.
- Coordinate Care Transitions: Initiate timely individualized care plans (ICPs) based on health risk assessments (HRAs), participate in and document interdisciplinary meetings (IDMs), and assist in transitions of care across all ages.
- Referral and Case Management: Determine the appropriateness of referrals for CM services, mental health, and social services, and provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance departments (AGD).
- Member Care Review: Conduct member care reviews with medical groups or individual providers for continuity of care, out-of-area/out-of-network, and investigational/experimental cases.
- Treatment Management: Manage member treatment to meet recommended length of stay, ensure DC planning at levels of care appropriate for member needs and acuity, and assess member health behaviors, cultural influences, and client belief/value systems.
- Continuous Improvement: Research opportunities for improvement in assessment methodology, actively promote continuous improvement, and anticipate potential barriers while establishing realistic goals to ensure success for members, providers, and Blue Shield of California.
- Strong Clinical Judgment: Demonstrate clinical judgment and independent analysis in performing utilization management (UM) and care management (CM) activities.
- Effective Communication: Collaborate with members, clinical nurses, treating physicians, and other healthcare professionals to ensure seamless care coordination.
- Business Acumen: Understand healthcare business operations, including contracts, reimbursement, and quality metrics.
