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Healthcare Professional for Integrated Case Management

2 weeks ago


Rancho Cordova, California, United States Blue Shield of California Full time

Job Overview

We are seeking a skilled Nurse Case Manager to join our Federal Employee Program (FEP) team. In this role, you will provide integrated case management and disease management activities, demonstrating clinical judgment and independent analysis.

About the Role

The Regional Registered Nurse Case Manager will report to the FEP Care Management Department Manager. Your primary responsibility will be to determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the member's needs.

Key Responsibilities

  • Care Coordination: Coordinate care for lower levels of care such as Skilled Nursing Facility, Home Health, Home Infusion, Acute Rehab, Long-term Acute Care Hospital, Hospice, and other community programs as appropriate.
  • Discharge Planning: Perform effective discharge planning and collaborate with members' support systems and healthcare professionals involved in the continuum of care.
  • Disease Management Education: Provide education on core chronic conditions, including Diabetes, Heart Failure, COPD, Asthma, and Coronary Artery Disease. Outreach to members with HEDIS Care Gaps to assist with closure.
  • Treatment/Plan Design: 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. Research and design 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.
  • Referrals and Quality Management: Provide referrals to Quality Management, Disease Management, and Appeals and Grievance departments. Recognize clients' rights to self-determination, including autonomy, and make informed choices that may not promote the best outcomes, as determined by the healthcare team.
  • Plan Adaptation: Design appropriate and fiscally responsible plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Initiate and implement appropriate modifications in the plan of care to adapt to changes occurring over time and through various settings.

Requirements

  • Licensure/Certification: Current CA RN License is required. A Bachelor of Science in Nursing or advanced degree is preferred. Certified Case Manager (CCM) Certification or eligibility to obtain certification is desired.
  • Experience: At least 5 years of prior experience in nursing, healthcare, or a related field is required. Managed care experience is preferred, with comprehensive knowledge of case management, discharge planning, utilization management, disease management, and community resources.
  • Skills and Qualifications: Strong electronic clinical documentation skills, independent problem identification, and resolution skills are essential. Knowledge of coordination of care, prior authorization, level of care, and length of stay criteria sets is desirable. Competent understanding of NCQA and federal regulatory requirements is necessary.

About Blue Shield of California

Blue Shield of California is committed to providing high-quality, affordable healthcare to its members. Our organization values professionalism, teamwork, and customer satisfaction. We offer competitive salaries and benefits packages to our employees, including opportunities for professional growth and development.