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Case Management - Nurse, Senior

  • Job
    Full-time
    Senior Level
  • Healthcare
  • $87.2K - $130.9K
  • San Diego, +2

AI generated summary

  • You need CA RN license, CCM certification, 5+ years experience in healthcare, 1+ year inpatient/outpatient setting, managed care knowledge, and transitions of care experience.
  • You will design care plans, manage treatment, assess members' needs, and collaborate with medical teams to ensure quality, cost-effective healthcare services for Blue Shield of California.

Requirements

  • Requires a 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 at least 5 years of prior experience in nursing, healthcare or related field
  • A minimum of 1 year experience in inpatient, outpatient or managed care environment required
  • Health insurance/managed care experience desired.
  • Transitions of care experience desired

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 qualifications are required for the Senior Case Management - Nurse position?

A current CA RN License, a Bachelor of Science in Nursing or advanced degree, Certified Case Manager (CCM) Certification or in process of completing certification, at least 5 years of prior experience in nursing or healthcare, a minimum of 1 year experience in inpatient, outpatient, or managed care environment, and health insurance/managed care experience are required for this position.

What are the responsibilities of the Senior Case Management - Nurse?

The Senior Case Management - Nurse is responsible for researching and designing treatment/care plans, initiating timely individualized care plans, determining appropriateness of referrals for CM services, conducting member care reviews, managing member treatment to meet recommended length of stay, assessing members' health behaviors, and developing appropriate plans of care with targeted interventions.

What experience is preferred for the Senior Case Management - Nurse position?

Transitions of care experience is desired for the Senior Case Management - Nurse position.

Who does the Senior Case Management - Nurse report to?

The Senior Case Management - Nurse reports to the Manager of Care Management.

What certifications are recommended for the Senior Case Management - Nurse position?

Certified Case Manager (CCM) Certification is recommended for the Senior Case Management - Nurse position.

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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.