Healthcare Specialist
5 days ago
At Blue Shield of California, we are dedicated to providing exceptional care management services to our members. We are seeking a highly skilled and compassionate Healthcare Specialist - Care Management to join our team.
About the RoleThis role will be responsible for ensuring that our members receive high-quality, cost-effective healthcare services. You will work closely with healthcare providers, community resources, and other stakeholders to coordinate care and develop individualized care plans.
You will also be responsible for conducting health risk assessments, participating in interdisciplinary meetings, and identifying opportunities for improvement in assessment methodology.
As a Healthcare Specialist - Care Management, you will have the opportunity to make a meaningful impact on the lives of our members and contribute to the success of our organization.
Key Responsibilities- Research and design treatment/care plans to promote quality of care and cost-effective healthcare services
- Initiate timely individualized care plans based on health risk assessment completion and participation in interdisciplinary meetings
- Determine appropriateness of referral for CM services, mental health, and social services
- Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance department (AGD)
- Conduct member care review 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 DC planning at levels of care appropriate for member needs and acuity
- Assess member health behaviors, cultural influences, and client belief/value system; evaluate information related to current/proposed treatment plan and identify potential barriers
- Current CA RN License
- Bachelor of Science in Nursing or advanced degree preferred
- Certified Case Manager (CCM) Certification or in process of completing certification when eligible
- At least 5 years of prior experience in nursing, healthcare, or related field
- A minimum of 3+ years managed care experience in inpatient, outpatient, or managed care environment preferred
- Health insurance/managed care experience preferred
- Transitions of care experience preferred
- Excellent communication skills
The estimated salary for this role is $87,230.00 to $130,900.00 per year, based on location and experience.
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