Case Management - Nurse, Consultant

JOB DESCRIPTION
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 Nurse Consultant will report to the Manager of Care Management for the Population Health Management Medi-Cal Team. 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:

• Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases.
• Participates in special projects as needed.
• 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.
• Performs precepting for new hires or those who are not meeting expectation.
• Assumes supervisor day to day responsibilities in manager’s absence and under the direction of the manager
• 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.
• 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.
• Determines realistic goals and objectives and provides appropriate alternatives. Actively solicits client’s involvement.
• 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.
• 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.
• Develops and implements the plan of care based on accurate assessment of the member and current of proposed treatment.
• 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).
• Initiation of timely individualized care plans (ICP) based on applicable assessments and assisting in transitions of care across all ages.
• Analyze productivity and internal reports to ensure compliance.
• Collaborates with department leadership to identify program development opportunities.
• 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.
• Mentors case managers with complex cases to promote quality of care, cost effective health care services based on medical necessity and complies with contract for each appropriate plan type

QUALIFICATIONS
Your Knowledge and Experience

• Transitions of care experience desired
• Health insurance/managed care experience desired.
• Requires at least 7 years of prior experience in nursing, healthcare or related field
• Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
• Requires a current CA RN License
• A minimum of 3+ year experience in inpatient, outpatient or managed care environment required

Pay Range:

The pay range for this role is: $ 109120.00 to $ 163680.00 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.

ABOUT THE TEAM
Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to diversity, equity, and inclusion combines a focus on our people, processes, and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in – join us!

Our Values:

• Honest . We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
• Human . We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.

Our Workplace Model:

Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That’s why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.

Two ways of working: Hybrid (our default) and office

• Hybrid – In a business unit approved office a few times per year to 3 days per week, on average

• Office – In a business unit approved office 4+ days a week, on average. If the role you’re applying for is deemed an “Essential Role,” the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

COVID-19 Vaccination Policy:

From the earliest days of the pandemic, Blue Shield of California has been unyielding in our commitment to putting the health and safety of our people, our members and our communities first. As a health care company, Blue Shield requires all employees to be up to date with COVID-19 vaccination prior to start date as a condition of employment. Blue Shield will consider requests for medical or religious accommodation to this vaccination requirement prior to your start date.

The definition of "up to date with your COVID-19 vaccine" is when you have received all doses in the primary series and one booster when eligible. If you are unable to be up to date with your COVID-19 vaccine by your start date, your start date will need to be postponed and you will have 30 days to remedy. If you cannot fulfill the requirement nor obtain accommodation within 30 days, your offer will be rescinded.