Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of California’s Mission is to ensure all Californians have access to high-quality care at an affordable price. Blue Shield is focused on improving health care delivery by working closely with providers and making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 4 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than $325 million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution.
We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone.
Case Managers perform a blended function of utilization management (UM) and case management (CM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating MD's. Determines develops and implements the plan of care based on accurate assessment of the member and current or proposed treatment plan in cases of:
- Member inquiry
- Triage hub
- Chronic conditions
- Prenatal care
- Voluntary member health assessment, in addition to indication of multiple monthly ER visits
Apply detailed knowledge of Blue Shield of California (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case. CM care typically lasts three months per member/patient.
Requires RN license and CM Certification at all levels. All levels require >80% Inter-Rater Reliability ratings, which test knowledge and skills based on hypothetical situations.
- Researches and designs 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.
- Implements discharge (DC) planning activities for medically complex cases.
- Determines appropriateness of referral for CM 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.
- Negotiates with employer groups when contractually required.
- 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.
- Researches 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 clients involvement.
- 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 or proposed treatment plan.
- Assists with precepting responsibilities for new hires and auditing efforts.
Additional Transplant CM Duties:
- Provides clinical input to medical directors.
- Conducts assessment and quality reviews of the BSC transplant network.
- Current knowledge of transplant service trends.
- Current CA RN License.
- Bachelors of Science in Nursing or advanced degree preferred.
- Certified Case Manager (CCM) or is in process of completing certification when eligible based on CCM application requirements.
- Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
- In depth understanding of community resources, treatment options, home health, funding sources and special programs.
- Extensive knowledge of evidenced based clinical practice guidelines particularly for chronic conditions.
- Incorporates professional judgment and critical thinking when determining medical necessity that promotes quality, cost-effective care.
- Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, 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.
- If certified as a CM, maintains CCM certification through continuing competence and education appropriate to case management scope of practice.
Minimum Experience Level:
- Generally requires moderate to extensive experience in nursing, health care or related field.
- Requires extensive experience in nursing, health care or related field, (5-7 years), 3+ yrs managed care experience preferred.
- Able to operate PC-based software programs including proficiency in Word and Excel.
- Monitors Clinical Support Coordinators (non-clinical) in the performance of UM support activities, QA and regular performance audits.
- Training and mentoring as backup to Lead as needed.
- Strong clinical documentation skills, independent problem identification and resolution skills.
- Strong verbal and written communication and negotiation skills.
- Works on projects with minimal supervision.
- Demonstrates cultural competence to work effectively, respectfully, and sensitively within the clients cultural context.
- Mentors, trains, performs to QA audits, employee evaluations and performance assessments in partnership with CM Lead.
- Advocates understanding and respect for the beliefs, value system, and decisions of the client.
- Recognizes the clients right to self-determination as it relates to the ethical principle of autonomy, including the client/family right to make informed choices that may not promote the best outcomes, as determined by the healthcare team. Advocates and strives to achieve consensus among all parties to promote positive client health and wellness outcomes.
- Represents the clients interests by advocating necessary funding, appropriate treatment and treatment alternatives, timely coordination of health services, and frequent re-evaluation of progress and goals.