Senior Registered Nurse Care Manager, Care Management

Company: Blue Shield of California
Location: Stratford
Posted on: February 21, 2021

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