Clinical Care Manager
2 months ago
About the Role
The Children's Health Program (CHP) team at Blue Shield of California provides identification, referrals, and care management for all Medi-Cal members under 21 years old and collaborates within the Promise Clinical Team. As a Case Management Nurse, Senior, you will report to the CHP Manager.
Your Responsibilities
- Perform clinical review, assessment, and evaluation of medical services for the organization using established and approved Blue Shield Medical Policies and CCS/EIES/DDS/ECM Eligibility guidelines, which align with nationally recognized standards.
- Manage member needs for specific CCS/EIES/DDS/CSHCN and other clinical programs and care coordination.
- Assist in daily inventory, provide high-quality clinical reviews, perform efficient care management and care coordination, and ensure compliance with performance metrics.
- Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
- Ensure discharge planning at levels of care appropriate for the member's needs and acuity and determine post-acute needs of the member, including levels of care, durable medical equipment, and post-service needs to ensure quality and cost-appropriate discharge planning.
- Prepare and present cases to the Medical Director for medical director oversight and necessity determination and communicate determinations to providers and/or members in compliance with state, federal, and accreditation requirements.
- Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays, and intervene or as clinically appropriate.
About the Team
The CHP team collaborates with County CCS and Regional Centers to provide comprehensive care management and care coordination services to our members.
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