Care Manager

3 days ago


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

We are seeking a highly skilled Care Manager to join our team at Blue Shield of California. As a key member of our Population Health Management Medi-Cal Team, you will play a critical role in supporting the mission of our department to provide high-quality care to our patients.

Key Responsibilities
  • Develop and Implement Care Plans: Research and design treatment/care plans to promote quality of care and cost-effective healthcare services based on medical necessity, complying with contract requirements for each plan type.
  • Coordinate Care Transitions: Initiate timely individualized care plans (ICPs) based on applicable assessments and assist in transitions of care across all ages.
  • Referral and Case Management: Determine the appropriateness of referrals for CM services, mental health, and social services, and provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance departments (AGD).
  • Member Care Review: Conduct member care reviews with medical groups or individual providers for continuity of care, out-of-area/out-of-network, and investigational/experimental cases.
  • Assessment and Planning: Assess members' health behaviors, cultural influences, and clients' belief/value systems, and evaluate all information related to current/proposed treatment plans and clinical practice guidelines to identify potential barriers.
  • Continuous Improvement: Research opportunities for improvement in assessment methodology and actively promote continuous improvement, anticipating potential barriers while establishing realistic goals to ensure success for members, providers, and Blue Shield.
  • Supervisory Responsibilities: Assume supervisor day-to-day responsibilities in the manager's absence and under the direction of the manager.
  • Productivity and Compliance: Analyze productivity and internal reports to ensure compliance, and collaborate with department leadership to identify program development opportunities.
  • Mentorship and Training: Mentor case managers with complex cases to promote quality of care and cost-effective healthcare services based on medical necessity, and perform precepting for new hires or those who are not meeting expectations.
Requirements
  • Current CA RN License: Possess a current California RN license.
  • Certified Case Manager (CCM) Certification: Hold a Certified Case Manager (CCM) certification or be in the process of completing certification when eligible based on CCM application requirements.
  • Experience and Education: Require at least 7 years of prior experience in nursing, healthcare, or a related field, and a minimum of 3+ years of experience in inpatient, outpatient, or managed care environments.
  • Health Insurance/Managed Care Experience: Possess health insurance/managed care experience, and transitions of care experience is desired.
  • Excellent Communication Skills: Demonstrate excellent communication skills.
Pay Range

The pay range for this role is: $109,120.00 to $163,680.00 for California.



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