Case Management - Nurse, Consultant

at  Blue Shield of California

YOUR WORK

In this role, you will:

• 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
• Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
• Leads team huddles/ meetings to support process and collaboration of team members
• Contributes to the adoption, evaluation and improvement of electronic medical record (EMR). Participates in go-live testing which may occur afterhours or on weekends, based on the posted monthly release schedule
• Works 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
• Contributes to the development of goals for the department and planning efforts (budgets, operational plans, etc.). Influences 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
• Issues faced are numerous and undefined, and require detailed information gathering, analysis and investigation to understand the problem

QUALIFICATIONSYOUR KNOWLEDGE AND EXPERIENCE

• 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 7 years of prior experience in nursing, healthcare or related field
• Demonstrated ability to test EMR systems and write acceptance criteria statements
• 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)
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable
• Demonstrated and evolving competence in CM functions and standards of practice
• 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
• Work is performed with limited oversight

PHYSICAL REQUIREMENTS:

Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

JOB DESCRIPTIONYOUR ROLE

The Federal Employee Program (FEP) Care Management team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with their care including a multidisciplinary team and the member’s treating physicians . The Registered Nurse Case Management Lead will report to the FEP Department Manager. In this role you will be responsible for exhibiting BSC leadership behaviors while supporting the overall FEP CM team as a subject matter expert.

In this role, you will:

• 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
• Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
• Leads team huddles/ meetings to support process and collaboration of team members
• Contributes to the adoption, evaluation and improvement of electronic medical record (EMR). Participates in go-live testing which may occur afterhours or on weekends, based on the posted monthly release schedule
• Works 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
• Contributes to the development of goals for the department and planning efforts (budgets, operational plans, etc.). Influences 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
• Issues faced are numerous and undefined, and require detailed information gathering, analysis and investigation to understand the proble