Job DescriptionYour Role The Care Management team coordinates, educates, and advocates care for the Dual-Special Needs (DSNP) population with Blue Shield of California. The Case Management - Nurse, Senior will report to the Manager of Care Management within Medical Care Solutions. In this role you will be responsible for managing a caseload of DSNP members, reviewing Health Risk Assessments and completing Individualized Care Plans, engaging members to reduce readmissions to the hospital, and supporting the DSNP care management team.
ResponsibilitiesYour 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.
- Initiate 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.
- Determine appropriateness of referral for CM services, mental health, and social services.
- Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD).
- Conduct member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases.
- Manage member treatment to meet recommended length of stay. Ensure DC planning at levels of care appropriate for the members' needs and acuity
- Assess 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 promote continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSC.
- Determine realistic goals and objectives and provide appropriate alternatives. Actively solicit client's involvement.
- Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjust plans or create contingency plans as necessary.
- Assess 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.
- Develop appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
- Recognize need for contingency plans throughout the healthcare process. Develop and implement the plan of care based on accurate assessment of the members and current of proposed treatment.
QualificationsYour Knowledge and Experience - Current CA RN License required
- Bachelor's 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
Our Workplace Model We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
- For most teams, this means coming into the office two days per week.
- Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
- For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
Physical Requirements:Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
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