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Case Management - Nurse, Consultant

  • Job
    Full-time
    Senior & Expert Level
  • Healthcare
  • $109.1K - $163.7K
  • Long Beach, +2

AI generated summary

  • You must have a CA RN License, 7+ years experience in healthcare, CCM certification or in process, extensive knowledge of clinical practice guidelines, experience with EMR systems, and cultural awareness. Being able to work independently and possessing strong analytical skills are a must.
  • You will manage caseloads, lead team meetings, develop goals, provide guidance, referrals, and training, and design care plans to enhance outcomes.

Requirements

  • Requires a current CA RN License. Bachelor of Science in Nursing or advanced degree preferred
  • Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
  • Requires at least 7 years of prior experience in nursing, healthcare or related field
  • Demonstrated ability to test EMR systems and guide the development of acceptance criteria statements to improve the EMR systems
  • Extensive knowledge of evidenced based clinical practice guidelines particularly for chronic conditions
  • Working knowledge of regulatory and accreditation standards 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 desirable
  • Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning
  • Excellent analytical and problem-solving skills
  • Strong clinical documentation skills, independent problem identification and resolution skills. Proficiency with 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 limited oversight

Responsibilities

  • Contribute to the adoption, evaluation, and ongoing improvement of CM electronic medical record (EMR). Participate in go-live testing which may occur afterhours or on weekends, based on the posted monthly release schedule
  • Work to achieve operational targets with significant impact on the departmental results with a concentration on system enhancements to improve the documentation process for the staff
  • Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
  • Lead team huddles/meetings to support process changes and encourage collaboration of team members
  • Contribute to the development of goals for the department and planning efforts (budgets, operational plans, etc.). Influence the performance of the business unit in achieving Blue Shield of California's objectives. Responsible for collecting data required for contractual reporting
  • Responsible for auditing, providing guidance, coaching, training and precepting to other employees within job area. Collaborate with the training department and operation department to customize training specific to the FEP team
  • 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 appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes

FAQs

What are the main responsibilities of a Case Management Nurse Consultant in the FEP Care Management team?

The main responsibilities include performing integrated case management and disease management activities, collaborating with members and their care team, demonstrating clinical judgment, providing independent analysis, and working with a multidisciplinary team and treating physicians.

Who does the Case Management Nurse Consultant report to in this role?

The Registered Nurse Case Management Lead will report to the FEP Department Manager.

What leadership behaviors are expected of the Case Management Nurse Consultant in this position?

The Case Management Nurse Consultant is expected to exemplify BSC leadership behaviors while supporting the overall FEP CM team as a subject matter expert.

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Finance
Industry
5001-10,000
Employees
1939
Founded Year

Mission & Purpose

Blue Shield of California strives to create a healthcare system worthy of its family and friends that is sustainably affordable. Blue Shield of California is a tax-paying, nonprofit, independent member of the Blue Shield Association with 4.7 million members, 7,800 employees, and $22.9 billion in annual revenue. Founded in 1939 in San Francisco and now headquartered in Oakland, Blue Shield of California and its affiliates provide health, dental, vision, Medicaid and Medicare healthcare service plans in California. Blue Shield of California complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.