Case Management

Company: Blue Shield of California
Location: Rancho Cordova
Posted on: October 3, 2024

Job Description:

Job Summary: The Senior Care Manager will support the mission of the department by providing care management services to patients in the outpatient setting, ensuring quality and cost-effective healthcare services.

The Senior Care Manager will report to the Manager of Care Management and will be responsible for coordinating care with specialists, community resources, and other healthcare providers to ensure that services are provided based on standardized procedures. The role will involve a blended function of utilization management and care management activities, demonstrating clinical judgment and independent analysis.

In this role, you will:

• 
  
• Research and design treatment/care plans to promote quality of care and cost-effective healthcare services based on medical necessity.
  
• Initiate timely individualized care plans based on health risk assessment completion, participation in, and documentation of interdisciplinary meetings.
  
• Determine the appropriateness of referral for care management services, mental health, and social services.
  
• Provide referrals to quality management, disease management, and appeals and grievance departments.
  
• Conduct member care reviews 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 and ensure DC planning at levels of care appropriate for the member's needs and acuity.
  
• Assess members' health behaviors, cultural influences, and clients' belief/value system, and evaluate all information related to current/proposed treatment plans.
  
• Research opportunities for improvement in assessment methodology and actively promote continuous improvement.
  
• Determine realistic goals and objectives and provide appropriate alternatives, actively soliciting clients' involvement.
  
• Design appropriate and fiscally responsible plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
  
• Assess and re-evaluate health and progress due to the dynamic nature of the plan of care required on an ongoing basis.
  
• Develop and implement the plan of care based on accurate assessment of the member and current or proposed treatment.
  
  
  Requirements:
  
  • 
    
  • Current CA RN License.
    
  • Bachelor's of Science in Nursing or advanced degree preferred.
    
  • Generally, requires moderate to extensive experience in nursing, healthcare, or related field.
    
  • Requires 5+ years' experience in nursing, healthcare, 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: $87,230.00 to $130,900.00 for California.

Keywords: Blue Shield of California, Cupertino , Case Management, Executive , Rancho Cordova, California