CRNA / Case Management / California / Permanent / Behavioral Health RN Case Manager Job

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.