Overview: 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, Home Health, Home Infusion, Rehab Provides 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.
