Clinical Case Management Specialist
2 weeks ago
Your Role
The Federal Employee Program (FEP) Care Management team is dedicated to executing integrated case management (CM) and disease management (DM) activities. This role requires the application of clinical judgment and independent analysis through collaboration with members and their care teams, including a multidisciplinary group and the member's healthcare providers.
The Registered Nurse Case Management Lead will report directly to the FEP Department Case Management Manager.
Your Work
In this position, you will:
- Research and develop treatment and care plans that enhance the quality of care while ensuring cost-effective healthcare services based on medical necessity, adhering to contractual obligations for each relevant plan type.
- Facilitate referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance departments (AGD).
- Uphold the client's right to self-determination in alignment with the ethical principle of autonomy, which includes the client/family's right to make informed decisions that may not align with the best outcomes as determined by the healthcare team.
- Create suitable and financially responsible care plans with targeted interventions aimed at improving quality, access, and cost-effective outcomes.
- Support the team through effective caseload management and workload distribution to meet team objectives, regulatory deadlines, and accreditation standards.
- Lead team meetings and huddles to foster collaboration among team members and maintain relational coordination with supportive teams.
- Work towards achieving operational goals that significantly influence departmental results.
- Contribute to departmental goal setting and planning initiatives (budgets, operational strategies, etc.). Influence the performance of the business unit in meeting Blue Shield of California's objectives. Responsible for gathering data necessary for contractual reporting.
- Oversee auditing processes, provide guidance, coaching, training, and mentoring to colleagues within the job area. Collaborate with the training and operations departments to tailor training specific to the FEP team.
- Address complex issues that require thorough information gathering, analysis, and investigation to fully understand the challenges.
Your Knowledge and Experience
Requires a current CA RN License.
Bachelor of Science in Nursing or an advanced degree is preferred.
Certified Case Manager (CCM) Certification or in the process of obtaining certification when eligible based on CCM application requirements.
Requires a minimum of 7 years of prior experience in nursing, healthcare, or a related field.
Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
Extensive knowledge of evidence-based clinical practice guidelines, particularly for chronic conditions.
Familiarity with regulatory and accreditation standards is preferred (NCQA, Case Management Society of America CMSA).
Demonstrated and evolving competence in CM functions and standards of practice.
Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care, and length of stay criteria sets is desirable.
Proficient analytical and problem-solving skills.
Strong clinical documentation skills, with the ability to identify and resolve issues independently.
Proficiency in Microsoft applications, including Word, Excel, Outlook, and Teams.
Possesses cultural awareness to work effectively, respectfully, and sensitively within the client's cultural context.
In-depth understanding of community resources, treatment options, home health, funding sources, and special programs.
Ability to work independently with minimal oversight.
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 various factors, including the candidate's experience, location, and current employee salaries for similar roles.
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