Case Management - Nurse, Senior

Blue Shield of California•Rancho Cordova, CA

About The Position

Your Role The Case Management team performs case management (CM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating MDs. The Case Management - Nurse, Senior will report to the Manager, Care Management. In this role you will determine, develop and implement the plan of care based on accurate assessment of the member and current or proposed treatment plan in cases of member inquiry, triage hub, chronic conditions, polypharmacy, pre-natal care, and voluntary member health assessment, in addition to indication of multiple monthly ER visits. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning. Responsibilities Your Work In this role, you will:

Requirements

Requires a bachelor's degree or equivalent experience
Requires a current California RN License
Requires at least 5 years of prior experience in nursing, healthcare or related field
Requires a Certified Case Manager (CCM) Certification or obtained within 18 months of hire
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
Professional judgment and critical thinking when determining medical necessity that promotes quality, cost-effective care
Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets
Proficiency in PC-based software programs including Microsoft Office 365 applications including Word, Excel, Outlook and Teams

Responsibilities

Research and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type
Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)
Recognize the clients’ right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
Design an appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes
Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings
Conduct member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases
Assess members’ health behaviors, cultural influences and clients belief/value system
Evaluate all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers
Research opportunities for improvement in assessment methodology and actively promote continuous improvement
Anticipate potential barriers while establishing realistic goals to ensure success for the members, providers and BSC
Adjust plans or create contingency plans as necessary
Assess and re-evaluate health and progress due to the dynamic nature of the plan of care required on an ongoing basis