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Case Manager - Nurse, Senior (Behavioral Health)

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

AI generated summary

  • You must possess a CA RN License, CCM Certification or eligible, 5+ years experience in healthcare, BSN preferred, strong behavioral health knowledge, PC skills, critical thinking, leadership and communication abilities.
  • You will coordinate care for behavioral health patients, design treatment plans, provide referrals, recognize patient autonomy, and collaborate with healthcare professionals for quality outcomes.

Requirements

  • Requires a current CA RN License
  • 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
  • Bachelor of Science in Nursing or advanced degree preferred
  • Requires relevant behavioral health experience
  • Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources.
  • Able to operate PC-based software programs including proficiency in Word and Excel
  • Strong clinical documentation skills, independent problem identification and resolution skills
  • Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills
  • Competent understanding of NCQA and federal regulatory requirements
  • Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable
  • Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care
  • Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making

Responsibilities

  • Coordinates care for Lower Level of Care such as Residential Treatment, Partial Hospitalization Program, Intensive Outpatient Program, other outpatient services, and community programs as appropriate.
  • 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 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
  • Applies detailed knowledge of FEP PPO and Blue Shield of California's (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case
  • Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care
  • Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease)
  • Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs related to behavioral health
  • Must be able to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentation

FAQs

What is the primary role of a Behavioral Health Registered Nurse Case Manager in this position?

The primary role of a Behavioral Health Registered Nurse Case Manager in this position is to determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the member's needs.

Who does the Behavioral Health Registered Nurse Case Manager collaborate with in this role?

The Behavioral Health Registered Nurse Case Manager collaborates with members and those involved with members' care including clinical nurses and treating physicians.

What type of activities does the Federal Employee Program (FEP) team perform in this position?

The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis.

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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.