Healthcare Coordination Specialist

1 week ago


Long Beach, California, United States Blue Shield of California Full time
Job Description:

We are seeking a skilled Healthcare Coordination Specialist - Behavioral Health RN to join our team at Blue Shield of California. In this role, you will play a vital part in coordinating care for members by developing and implementing individualized treatment plans based on comprehensive assessments.

This position involves collaborating with healthcare professionals to ensure quality, effective, and cost-efficient care, as well as providing education on chronic conditions. The ideal candidate will have a valid California RN license, case management certification, and significant experience in nursing and behavioral health.

The salary for this role is $87,230.00 to $130,900.00 per year, making it an attractive opportunity for those looking to advance their careers in the field of healthcare coordination.

Responsibilities:
  • Coordinate care for Lower Level of Care such as Residential Treatment, Partial Hospitalization Program, Intensive Outpatient Program, other outpatient services, and community programs as appropriate
  • 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, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
  • 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
  • Applies 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
  • Performs effective discharge planning and collaborates 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)
  • Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs related to behavioral health
Requirements:
  • Bachelor of Science in Nursing or advanced degree preferred
  • Requires a current CA RN License
  • Certified Case Manager (CCM) Certification or is 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
  • Requires relevant behavioral health experience
  • 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 the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care
  • Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making


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