Behavioral Health Case Manager
3 days ago
Your Role
The Behavioral Health Registered Nurse Case Manager will report to the FEP Department Manager. In this role, you will be responsible for determining, developing, and implementing a plan of care based on accurate and comprehensive assessments of members' needs. This plan will focus on promoting quality, cost-effective care, and will involve collaborating with members, clinical nurses, and treating physicians. The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities, demonstrating clinical judgment and independent analysis.
- Coordinate care for members requiring lower levels of care, such as residential treatment, partial hospitalization programs, intensive outpatient programs, and community programs as appropriate.
- Research and design treatment/care plans to promote quality of care, cost-effective health services based on medical necessity, and comply with contracts for each appropriate plan type.
- Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance departments (AGD).
- Recognize members' rights to self-determination, including their right to make informed choices that may not promote the best outcomes, as determined by the healthcare team.
- Design appropriate and fiscally responsible plans of care with targeted interventions that 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.
- Requires a current California RN license, certification as a Certified Case Manager (CCM), and at least 5 years of prior experience in nursing, healthcare, or a related field. Preferably, you should have 3+ years of managed care experience and a Bachelor of Science in Nursing or an advanced degree.
- 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, and 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 levels of care.
- Demonstrate 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: $ to $ 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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