Care Management - Nurse, Senior (FEP - Triage)

Blue Shield of California•El Dorado, AR

18d•Remote

About The Position

The Federal Employee Program (FEP) team performs integrated case management and disease management, applying clinical judgment and independent analysis while collaborating with members and people involved in their care, including clinical nurses and treating physicians. The Complex Care Coordination Triage Registered Nurse Case Manager determines, develops, and implements plans of care based on accurate, comprehensive assessments of member needs. The role reports to the FEP Care Manager Department Manager. The position coordinates access to medically necessary services, triages referrals, provides disease-management education, supports care transitions and discharge planning, and develops individualized care plans responsive to members’ medical and behavioral health needs. Employees work virtually full-time, with office attendance expected as business needs require. The role requires extended periods of sitting and the ability to read information on one computer screen and apply it on a second screen for documentation.

Requirements

Associate Degree in Nursing.
Active, unrestricted California RN license.
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, communication, abstracting, and negotiation skills.
Competent understanding of NCQA and federal regulatory requirements.
Professional judgment and critical-thinking skills to promote quality, cost-effective care based on medical necessity, intensity of service, severity of illness, contracted benefits, and appropriate level of care.
Leadership, project management, and program evaluation skills, with the ability to interact with all levels, including senior management, and influence decision-making.
Ability to sit for extended periods and read information on one computer screen while applying it on a second computer screen.

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 help members access medically necessary services within the access network and plan benefits.
Triage referrals from the 24-hour Nurse Line to help ensure members see providers promptly and receive necessary health-condition education.
Work with providers and internal departments to initiate the Letter of Agreement (LOA) and exception processes.
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 closing them.
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 community programs, as appropriate.
Respect clients’ right to self-determination and autonomy, including the right of clients and families to make informed choices that may not promote the outcomes the healthcare team considers best.
Apply knowledge of FEP PPO and Blue Shield of California policies, clinical practice guidelines, community resources, contracting, and community care standards to cases.
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 plans as needs evolve to promote quality, accessible, and cost-effective care.
Complete documentation while reading information on one computer screen and applying it on a second screen.