Care Management - Nurse, Senior (FEP - Triage)

Blue Shield of California•El Dorado Hills, CA

5h•$90,860 - $153,636•Hybrid

About The Position

The Federal Employee Program (FEP) team performs integrated case management and disease management, using clinical judgment and independent analysis while collaborating with members, clinical nurses, treating physicians, and others involved in members’ care. The Complex Care Coordination Triage Registered Nurse Case Manager determines, develops, and implements plans of care based on accurate, comprehensive assessment of members’ needs. The role reports to the FEP Care Manager Department Manager. The position supports members in accessing medically necessary services, triages referrals from the 24-hour Nurse Line, provides condition-specific education, and coordinates care transitions and discharge planning. It develops and updates individualized care plans for members’ medical and behavioral health needs, while considering covered benefits and available services. The role applies FEP PPO and Blue Shield of California policies and guidelines, identifies potential quality-of-care issues, and promotes quality, accessible, and cost-effective care. This role allows employees to work virtually full-time, with office attendance as required by business needs. Employees should be able to sit for extended periods and use two computer screens to review information and complete documentation.

Requirements

Associate Degree in Nursing.
Active, unrestricted California RN license that must be maintained.
At least 5 years of prior experience in nursing, healthcare, or a related field.
Comprehensive knowledge of case management, discharge planning, utilization management, disease management, and community resources.
Ability to operate PC-based software, including proficiency in Word and Excel.
Strong clinical documentation, independent problem identification, and resolution skills.
Strong supervisory, communication, abstracting, verbal and written communication, and negotiation skills.
Competent understanding of NCQA and federal regulatory requirements.
Professional judgment and critical thinking to promote quality, cost-effective care, including assessment of medical necessity, intensity of service, severity of illness, contracted benefits, and appropriate level of care.
Leadership, project management, and program evaluation skills, and ability to interact with all levels, including senior management, and influence decision-making.

Nice To Haves

Bachelor of Science in Nursing or an advanced degree.
Certified Case Manager (CCM) certification.
Knowledge of coordination of care, prior authorization, and level-of-care and length-of-stay criteria sets.

Responsibilities

Conduct provider searches and assist members in accessing medically necessary services within the access network and plan benefits.
Triage referrals from the 24-hour Nurse Line to help members see providers in a timely manner and receive necessary health-condition education.
Work with providers and internal departments to initiate the Letter of Agreement (LOA) and Exception process.
Provide disease management education on core chronic conditions, including diabetes, heart failure, COPD, asthma, and coronary artery disease, as well as rare conditions.
Reach out to members with HEDIS Care Gaps to assist with closure.
Perform discharge planning and collaborate with members’ support systems and health care professionals across the continuum of care.
Coordinate transitions to lower levels of care, such as skilled nursing facilities, home health, home infusion, acute rehabilitation, and other appropriate community programs.
Respect clients’ right to self-determination and informed choices, including choices that may not promote the outcomes preferred by the healthcare team.
Apply knowledge of FEP PPO and Blue Shield of California policies, clinical practice guidelines, community resources, contracting, and community care standards to each case.
Identify and report potential quality-of-care issues to the Quality Management and Appeals & Grievance Departments.
Develop individualized care plans based on members’ medical and behavioral health needs, covered benefits, and available services.
Review and update care plans as members’ needs evolve to promote quality, accessible, and cost-effective care.
Sit for extended periods and read information on one computer screen while applying that information on a second screen to complete documentation.