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Case Management - Nurse, Senior

  • Job
    Full-time
    Senior Level
  • Healthcare
  • $87.2K - $130.9K
  • Long Beach, +2

AI generated summary

  • You must have a current CA RN license, CCM certification (or in process), 5+ years in nursing/healthcare, 3+ years managed care experience, transitions of care experience, and excellent communication skills.
  • You will research and design treatment plans, assess health behaviors, manage member care, plan interventions, and ensure cost-effective outcomes for Blue Shield of California.

Requirements

  • Current CA RN License. Bachelors 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 5+ years’ experience in nursing, health care or related field.
  • 3+ years managed care experience preferred. Health insurance/managed care experience desired.
  • Transitions of care experience preferred
  • Excellent communications skills

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.
  • Initiation of timely individualized care plans (ICP) based on health risk assessment (HRA) completion, participation in and documentation of interdisciplinary meetings (ICT), assisting in transitions of care across all ages.
  • Determines appropriateness of referral for CM services, mental health, and social services.
  • Provides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD).
  • Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases.
  • Manages member treatment in order to meet recommended length of stay. Ensures DC planning at levels of care appropriate for the members needs and acuity.
  • Assessment: Assesses members health behaviors, cultural influences and clients belief/value system. Evaluates 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 promotes continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSC.
  • Determines realistic goals and objectives and provides appropriate alternatives. Actively solicits client’s involvement.
  • Planning: Designs appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjusts plans or creates contingency plans as necessary.
  • Assesses and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settings.
  • Develops appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
  • Recognizes need for contingency plans throughout the healthcare process.
  • Develops and implements the plan of care based on accurate assessment of the member and current of proposed treatment.

FAQs

What are the main responsibilities of a Senior Care Manager in this role?

The main responsibilities include coordinating care with specialists and community resources, performing utilization management and care management activities, demonstrating clinical judgement, and collaborating with members and healthcare providers involved in the member's care.

Who does the Senior Care Manager report to in this position?

The Senior Care Manager reports to the Manager of Care Management.

What is the mission of the Care Management team in this role?

The mission of the Care Management team is to provide support to patients in maintaining health and wellness in the outpatient setting.

What are some key skills and qualities needed to be successful as a Senior Care Manager?

Some key skills and qualities include strong clinical judgement, independent analysis, ability to collaborate with others involved in patient care, and proficiency in coordinating care with specialists and community resources.

How does the Senior Care Manager ensure that services are provided based on standardized procedures?

The Senior Care Manager ensures that services are provided based on standardized procedures by following established protocols and guidelines for coordination of care, utilization management, and care management activities.

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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.