Senior Registered Nurse Care Manager, Care Management at Blue Shield Of California in Rancho Cordova, CA

Specific Responsibilities Include:

• 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.
• 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.
• 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 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 or proposed treatment plan.

Specialty Areas:

• 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 client’s cultural context.
• Mentors, trains, performs to QA audits, employee evaluations and performance assessments in partnership with CM Lead.
• Member Advocacy: 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.
• Demonstrates cultural competence to work effectively, respectfully, and sensitively within the client’s cultural context.
• Assists with precepting responsibilities for new hires and auditing efforts.

Qualifications

Minimum Education & Experience Requirements:

• A minimum of a bachelor’s degree in Nursing (BSN)from a regionally accredited college or university or associate degree in Nursing (ADN) and a bachelor’s degree in a different field.
• A minimum of 3 years’ experience in inpatient, outpatient or managed care environment.
• A minimum of 5 years’ combined experience in clinical nursing practice in the hospital, outpatient or managed care setting.
• Licensure as a Registered Nurse (RN)
• Certified Case Manager (CCM) or related board certification from a nationally recognized entity, i.e. ACM

Knowledge and Skills:

• Health insurance/managed care experience (Commercial, Medicare, and Medi-Cal)
• Lean methodology
• Excellent presentation and procedure-writing skills
• Excellent communication skills
• Transitions of care
• Community resources and advocacy
• Practice integration in a triad model of care
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