Case Manager

1 week ago

Oakland, California, United States Blue Shield of California Full time
About the Role

We are seeking a skilled Behavioral Health Registered Nurse Case Manager to play a critical role in delivering high-quality, cost-effective care to our members.

Key Responsibilities
  • Coordinate care for Lower Level of Care services, including Residential Treatment, Partial Hospitalization Program, Intensive Outpatient Program, and community programs.
  • Design treatment/care plans to promote quality of care and cost-effective health care services based on medical necessity and contracted benefits.
  • Provide referrals to Quality Management, Disease Management, and Appeals and Grievance departments.
  • Recognize the client's right to self-determination and autonomy, including the right to make informed choices that may not promote the best outcomes.
  • Design and implement a plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
  • Initiate and implement modifications in the plan of care to adapt to changes occurring over time and through various settings.
  • Apply detailed knowledge of FEP PPO and Blue Shield's established medical/departmental policies, clinical practice guidelines, community resources, and contracting 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 a plan of care based on accurate and comprehensive assessment of the member's needs related to behavioral health.
Requirements
  • Current CA RN License
  • Certified Case Manager (CCM) Certification or in process of completing certification
  • At least 5 years of prior experience in nursing, healthcare, or related field
  • Bachelor of Science in Nursing or advanced degree preferred
  • 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
Pay Range

The pay range for this role is: $ to $ for California.

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, and current employee salaries for similar roles.

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