Your Role

The Care Management team will serve to support the mission of the department, which is to provide support to patients in maintaining health and wellness in the outpatient setting. The Senior Care Manager will report to the Manager of Care Management. In this role you will ensure that services are provided based on standardized procedures including coordination of care with specialists, community resources. Care Managers perform a blended function of utilization management (UM) and care management (CM) activities demonstrating clinical judgement and independent analysis, collaborating with members and those involved with members' care including clinical nurses and treating physicians.

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.
• 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.
• Research 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 of proposed treatment.

Your Knowledge and Experience

• Current CA RN License.
• Bachelors of Science in Nursing or advanced degree preferred.
• Generally, requires moderate to extensive experience in nursing, health care or related field.
• Requires 5+ years' experience in nursing, health care or related field.
• 3+ years managed care experience preferred.
• Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements.
• A minimum of 3 years experience in inpatient, outpatient or managed care environment preferred
• Health insurance/managed care experience desired.
• Transitions of care experience desired
• Excellent communications skills
• Bilingual in English and Spanish preferred

Pay Range:

The pay range for this role is: $ 87230.00 to $ 130900.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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