Care Manager
21 hours ago
The Care Management team at Blue Shield of California plays a vital role in supporting the mission of the department, which is to provide comprehensive support to patients in maintaining health and wellness in the outpatient setting.
As a Senior Care Manager, you will report to the Manager of Care Management and be responsible for ensuring that services are provided based on standardized procedures, including coordination of care with specialists and community resources.
Your WorkIn this role, you will:
- Design and implement 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.
- Initiate timely individualized care plans (ICPs) based on health risk assessments (HRAs), participation in and documentation of interdisciplinary meetings (ICTs), and assistance in transitions of care across all ages.
- Determine the appropriateness of referrals for CM services, mental health, and social services.
- Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance departments (AGDs).
- Conduct member care reviews 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, ensuring DC planning at levels of care appropriate for the member's needs and acuity.
- Assess members' health behaviors, cultural influences, and clients' belief/value systems, evaluating all information related to current/proposed treatment plans and clinical practice guidelines to identify potential barriers.
- Research opportunities for improvement in assessment methodology and actively promote continuous improvement, anticipating potential barriers while establishing realistic goals to ensure success for the member, providers, and Blue Shield of California.
- Determine realistic goals and objectives, providing appropriate alternatives, and actively soliciting clients' involvement.
- Design and implement appropriate and fiscally responsible plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes, adjusting plans or creating contingency plans as necessary.
- Assess and re-evaluate health and progress due to the dynamic nature of the plan of care required on an ongoing basis, initiating and implementing appropriate modifications in the plan of care to adapt to changes occurring over time and through various settings.
- Develop and implement plans of care based on accurate assessments of the member and current/proposed treatment plans.
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