Behavioral Health Case Manager
3 days ago
About the Role
We are seeking a skilled Behavioral Health Case Manager to join our team at Blue Shield of California. In this role, you will play a vital part in determining, developing, and implementing plans of care based on comprehensive assessments of members' needs.
Your Work
- Coordinate care for lower levels of care, including residential treatment, partial hospitalization programs, intensive outpatient programs, other outpatient services, and community programs as necessary.
- 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 plan type.
- Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance department (AGD).
- Recognize clients' rights to self-determination, including autonomy, informed choices, and right to make decisions that may not promote best outcomes, as determined by the healthcare team.
- Design appropriate and fiscally responsible plans of care with targeted interventions to enhance quality, access, and cost-effective outcomes.
- Initiate and implement modifications in plans 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 systems and healthcare professionals involved in the continuum of care.
- Provide disease management education on core chronic conditions, including Diabetes, Heart Failure, COPD, Asthma, and Coronary Artery Disease.
- Determine, develop, and implement plans of care based on accurate and comprehensive assessments of members' needs related to behavioral health.
- You must be able to sit for extended periods, read information on one computer screen, and apply it to a second screen to complete documentation.
About You
- Bachelor of Science in Nursing or advanced degree preferred.
- Requires current CA RN License.
- Certified Case Manager (CCM) Certification or in process of completing certification when eligible based on CCM application requirements.
- Requires at least 5 years of prior experience in nursing, healthcare, or related field.
- 3+ years managed care experience preferred.
- Relevant behavioral health experience required.
- 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.
- 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 delivery of quality, cost-effective care.
- Demonstrates leadership, project management, and program evaluation skills and ability to interact with all levels, including senior management, and influence decision-making.
Compensation
The estimated salary range for this role is $87,230 - $130,900 per year, depending on location and experience.
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