Case Manager
1 day ago
Job Summary:
We are seeking a highly skilled and experienced Case Manager to join our team at Blue Shield of California. As a Case Manager, you will be responsible for conducting comprehensive assessments of members' needs, developing and implementing individualized care plans, and coordinating with healthcare providers to ensure optimal care and outcomes.
Key Responsibilities:
- Conduct thorough assessments of members' needs and develop personalized care plans
- Collaborate with healthcare providers to ensure timely and effective care
- Coordinate with internal departments to initiate the Letter of Agreement (LOA) and Exception process
- Outreach to members with HEDIS Care Gaps to assist with closure
- Research and design treatment/care plans to promote quality of care and cost-effective health services
- Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance department (AGD)
- Recognize members' rights to self-determination and autonomy
- Design and implement appropriate and fiscally responsible plans of care
- Initiate and implement modifications to plans of care as needed
- 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
- Perform effective discharge planning and collaborate with member support systems and healthcare professionals
- Coordinate care for lower levels of care coordination, such as Skilled Nursing Facility, Home Health, Home Infusion, Rehab, and other community programs as appropriate
- 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
Requirements:
- Current CA RN License
- 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
- 3+ years managed care experience preferred
- Bachelor of Science in Nursing or advanced degree preferred
- 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
- Demonstrates leadership, project management, and program evaluation skills and ability to interact with all levels, including senior management, and influence decision-making
Pay Range:
The pay range for this role is: $87,230.00 to $130,900.00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
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