Senior Registered Nurse Care Manager, Care Management
Company: Blue Shield of California
Location: Stratford
Posted on: February 21, 2021
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Job Description:
The Senior Registered Nurse Care Manager will report to the
Senior Manager of Care Management and 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 Registered Nurse Care Manager performs--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.
The Senior Registered Nurse Care Manager develops and implements
the plan of care based on accurate assessment of the member using
current or proposed treatment plan in cases of: member inquiry,
triage hub, chronic conditions, poly-pharmacy, pre-natal care, and
voluntary member health assessment, in addition to indication of
multiple monthly ER visits. The CM applies detailed knowledge of
Blue Shield of California (BSC) and Blue Shield Promise Health plan
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. The care manager will reinforce pillars of care,
that include but not limited to increasing quality of patient care
and access while improving member satisfaction. The Senior
Registered Nurse Care Manager must have extensive background of the
care management operations and a solid knowledge of community
resources, best practices, and the promotion holistic and
integrated high-tech and high-touch approach to medical care
management. The selected candidate will also have knowledge of
Medicare and Medi-Cal regulations, processes for dual eligible
members, Medi-Cal SPD, Medicare Advantage, and other programs and
services.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.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. ACMKnowledge 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
Keywords: Blue Shield of California, Visalia , Senior Registered Nurse Care Manager, Care Management, Executive , Stratford, California
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