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: <ul> <li>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. </li> <li>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. </li> <li>Determines appropriateness of referral for CM services, mental health, and social services.</li> <li>Provides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD). </li> <li>Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases. </li> <li>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. </li> <li>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. </li> <li>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. </li> <li>Determines realistic goals and objectives and provides appropriate alternatives. Actively solicits client's involvement. </li> <li>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. </li> <li>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. </li> <li>Develops appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. </li> <li>Recognizes need for contingency plans throughout the healthcare process. </li> <li>Develops and implements the plan of care based on accurate assessment of the member and current of proposed treatment.</li> </ul>Your Knowledge and Experience<ul><li>Current CA RN License.</li><li>Bachelors of Science in Nursing or advanced degree preferred.</li><li>Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements</li><li>Requires at least 5 years of prior experience in nursing, healthcare or related field</li><li>A minimum of 3 years experience in inpatient, outpatient or managed care environment required</li><li>Health insurance/managed care experience desired.</li><li>Transitions of care experience desired</li><li>Excellent communications skills</li></ul>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.<img src="https://www.jobg8.com/Tracking.aspx?MAYBxIqqWWbqjyWFQFDD6Qf" width="0" height="0" />

The Senior Care Manager supports patient health and wellness in outpatient settings, coordinating care with specialists and community resources. Responsibilities include designing treatment plans, assessing health risks, managing transitions of care, and ensuring cost-effective health services. The role requires clinical judgment, collaboration with healthcare providers, and continuous improvement in care methodology. Ideal candidates have a CA RN license, nursing experience, and excellent communication skills.

**Senior Care Manager**

**Job Description:**

The Care Management team supports the mission of the department to provide assistance to patients in maintaining health and wellness in the outpatient setting. The Senior Care Manager reports to the Manager of Care Management and ensures that services are delivered based on standardized procedures, including the coordination of care with specialists and community resources. Care Managers perform a blend of utilization management (UM) and care management (CM) activities, demonstrating clinical judgment and independent analysis, collaborating with members and those involved in members' care, including clinical nurses and treating physicians.

**Responsibilities:**

- Research and design treatment/care plans to promote quality of care and cost-effective health care services based on medical necessity, complying with contract for each appropriate plan type.
- Initiate timely individualized care plans (ICP) based on health risk assessment (HRA) completion, participate in and document interdisciplinary meetings (ICT), and assist in transitions of care across all ages.
- Determine appropriateness of referral for CM services, mental health, and social services.
- Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance department (AGD).
- 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. Ensure DC planning at levels of care appropriate for the members' needs and acuity.
- Assess members' health behaviors, cultural influences, and belief/value systems. Evaluate all information related to current/proposed treatment plans in accordance with clinical practice guidelines to identify potential barriers.
- Research opportunities for improvement in assessment methodology and actively promote continuous improvement. Anticipate potential barriers while establishing realistic goals to ensure success for the member, providers, and BSC.
- Determine realistic goals and objectives and provide appropriate alternatives. Actively solicit client involvement.
- Plan and design appropriate and fiscally responsible plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjust plans or create contingency plans as necessary.
- Assess and re-evaluate health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings.
- 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.
- Certified Case Manager (CCM) Certification or in the process of completing certification when eligible based on CCM application requirements.
- At least 5 years of prior experience in nursing, healthcare, or a related field.
- A minimum of 3 years of experience in inpatient, outpatient, or managed care environment required.
- Health insurance/managed care experience desired.
- Transitions of care experience desired.
- Excellent communications skills.

**Compensation:**

The pay range for this role is $87,230.00 to $130,900.00 for California.

**Note:**

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.

Case Management - Nurse, Senior

Your Role The Medi-Cal Member Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either a preservice, post-service or claim denial. The Medi-Cal Appeals and Grievances RN Senior will report to the Appeals and Grievances Manager. In this role you will perform accurate and timely clinical review of Member-initiated appeals. The RNs perform first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, Milliman Care Guidelines, and nationally recognized sources such as NCCN and ACOG. The successful RN candidate will review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy and medical policy compliance. In this role you will also perform Clinical oversight of all Medi-Cal grievances. In this process, the candidate will work with the medical directors and coordinators to identify any Potential Quality Issues (PQI), Quality of Service (QOS) cases and/or Quality of Care (QOC) cases to ensure member's clinical needs are addressed appropriately within 30 days or 72 hours if the request is deemed expedited. Your Work In this role, you will: <ul> <li>Identify issues, and with assistance, execute corrective action</li> <li>Intake Queue</li> <li>Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination </li> <li>Communicates determinations to the providers in compliance with state, federal and accreditation requirements</li> <li>Works well in a fast paced, production environment</li> <li>Initiates appropriate referrals for member's needs to other departments such as Case Management.</li> </ul>Your Knowledge and Experience <ul> <li>Bachelors of Science in Nursing or advanced degree preferred.</li> <li>Requires a current California RN License </li> <li>Requires at least 5 years of prior relevant experience</li> <li>Proficient skills with Microsoft Office Suite</li> <li>Knowledge of CPT, ICD-10, HCPCS and billing practices</li> <li>Knowledge of Medicare and Medi-Cal and benefit reviews preferred</li> <li>Demonstrate the ability to act independently using sound clinical judgement</li> <li>Requires advanced knowledge of appeals and grievances typically obtained through advanced education combined with experience. </li> <li>Solid communication skills</li> </ul> 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. <img src="https://www.jobg8.com/Tracking.aspx?j7gyGnmDtKqceCAqarARIwg" width="0" height="0" />

The Medi-Cal Appeals and Grievances RN Senior performs clinical reviews of member appeals and grievances related to preservice, post-service, or claim denial. Responsibilities include reviewing inpatient and outpatient Medicare appeals, ensuring compliance with guidelines, identifying quality issues, and communicating determinations. This role requires a California RN License, advanced knowledge of appeals processes, proficiency in billing practices, and the ability to act independently using sound clinical judgment.

**Medi-Cal Appeals and Grievances RN Senior**

**Job Description:**

- Perform accurate and timely clinical review of Member-initiated appeals
- Conduct first level appeal reviews using National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, Milliman Care Guidelines, and nationally recognized sources such as NCCN and ACOG
- Review both inpatient and outpatient Medicare member appeals for benefits, medical necessity, coding accuracy, and medical policy compliance
- Perform clinical oversight of all Medi-Cal grievances, working with medical directors and coordinators to identify Potential Quality Issues (PQI), Quality of Service (QOS) cases, and/or Quality of Care (QOC) cases
- Ensure member's clinical needs are addressed appropriately within 30 days or 72 hours if expedited

**Responsibilities:**

- Identify issues and execute corrective action with assistance
- Manage Intake Queue
- Prepare and submit clinical case reviews to the Medical Director for collaboration and medical necessity determination
- Communicate determinations to providers in compliance with state, federal, and accreditation requirements
- Work well in a fast-paced, production environment
- Initiate appropriate referrals for member's needs to other departments such as Case Management

**Requirements:**

- Bachelors of Science in Nursing or advanced degree preferred
- Current California RN License required
- At least 5 years of relevant experience required
- Proficient skills with Microsoft Office Suite
- Knowledge of CPT, ICD-10, HCPCS, and billing practices
- Knowledge of Medicare, Medi-Cal, and benefit reviews preferred
- Ability to act independently using sound clinical judgment
- Advanced knowledge of appeals and grievances typically obtained through advanced education combined with experience
- Solid communication skills

**Compensation:**

The pay range for this role is $87,230.00 to $130,900.00 for California. 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.

Appeals and Grievances - RN, Senior

Care Managers perform integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating physicians. Care Managers determine, develop and implement a plan of care based on accurate and comprehensive assessment of the members needs. Care Managers apply detailed knowledge of Blue Shield of California (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case. Responsibilities:Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the members needs. Applies detailed knowledge of FEP PPO and Blue Shield of Californias (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case. Works with complex cases, promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits.Provides guidance to the provider network.Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care.Coordinates Care for Lower Level of Care coordination such as Skilled Nursing Facility, Residential Treatment Center, Home Health, Home Infusion, RehabProvides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease).Makes referrals to Quality Management, Catastrophic Case Management and Appeals and Grievance Department.Additional Skills:Able to operate PC-based software programs including proficiency in Word and Excel.Strong clinical documentation skills, independent problem identification and resolution skills.Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills. Competent understanding of NCQA and federal regulatory requirements. Knowledge of Coordination of Care, prior authorization, level of care and length of stay criteria sets desirable. Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care. Solid case preparationDemonstrated leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making.<img src="https://www.jobg8.com/Tracking.aspx?qkvuLhrZfnw0rcKzWao%2bxwt" width="0" height="0" />

Care Managers conduct integrated case and disease management activities, utilizing clinical judgment and independent analysis. They collaborate with clinical nurses and physicians, develop and implement care plans, and ensure quality, cost-effective healthcare services. Responsibilities include effective discharge planning, care coordination for various facilities, disease management education, and referrals to relevant departments. They possess strong documentation, problem-solving, communication, and negotiation skills, and demonstrate professional judgment and leadership.

**Care Manager**

**Job Description:**

- Perform integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis.
- Collaborate with members and those involved with members' care, including clinical nurses and treating physicians.
- Determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the members' needs.
- Apply detailed knowledge of Blue Shield of California (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting, and community care standards to each case.

**Responsibilities:**

- Determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the members' needs.
- Apply detailed knowledge of FEP PPO and Blue Shield of California's (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting, and community care standards to each case.
- Work with complex cases and promote the delivery of quality, cost-effective health care services based on medical necessity and contractual benefits.
- Provide guidance to the provider network.
- Perform effective discharge planning and collaborate with member support systems and health care professionals involved in the continuum of care.
- Coordinate care for lower levels of care coordination such as Skilled Nursing Facility, Residential Treatment Center, Home Health, Home Infusion, Rehab.
- Provide disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma, and Coronary Artery Disease).
- Make referrals to Quality Management, Catastrophic Case Management, and Appeals and Grievance Department.

**Additional Skills:**

- Able to operate PC-based software programs, including proficiency in Word and Excel.
- Strong clinical documentation skills, independent problem identification and resolution skills.
- Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills.
- Competent understanding of NCQA and federal regulatory requirements.
- Knowledge of Coordination of Care, prior authorization, level of care, and length of stay criteria sets desirable.
- Demonstrate professional judgment and critical thinking to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity, including intensity of service and severity of illness within contracted benefits and appropriate level of care.
- Solid case preparation.
- Demonstrated leadership, project management, and program evaluation skills and ability to interact with all levels, including senior management, and influence decision-making.

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