Your Role
The Federal Employee Program (FEP) Care Management team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis by collaborating with members and those involved with their care including a multidisciplinary team and the member's treating physicians. The Registered Nurse Case Management Lead will report to the FEP Department Case Management Manager. In this role you will be responsible for supporting the overall FEP CM team as a subject matter expert while exemplifying BSC leadership behaviors.
Your Work
In this role, you will:
- 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
- Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)
- Recognize the clients right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
- Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes
- Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
- Leads team huddles/ meetings to support process and collaboration of team members and maintain relational coordination between supportive teams
- Works to achieve operational targets with significant impact on the departmental results
- Contribute to the development of goals for the department and planning efforts (budgets, operational plans, etc.). Influence the performance of the business unit in achieving Blue Shield of California's objectives. Responsible for collecting data required for contractual reporting
- Responsible for auditing, providing guidance, coaching, training and precepting to other employees within job area. Collaborate with the training department and operation department to customize training specific to the FEP team
- Issues faced are numerous and undefined, and require detailed information gathering, analysis and investigation to understand the problem
Your Knowledge and Experience
- Requires a current CA RN License. Bachelor of Science in Nursing or advanced degree preferred
- Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
- Requires at least 7 years of prior experience in nursing, healthcare or related field
- Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning
- Extensive knowledge of evidenced based clinical practice guidelines particularly for chronic conditions
- Working knowledge of regulatory and accreditation standards preferred (NCQA, Case Management Society of America CMSA). Demonstrated and evolving competence in CM functions and standards of practice
- Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable
- Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning
- Excellent analytical and problem-solving skills
- Strong clinical documentation skills, independent problem identification and resolution skills. Proficiency with Microsoft applications including Word, Excel, Outlook, and Teams
- Possesses cultural awareness to work effectively, respectfully, and sensitively within the client's cultural context
- In depth understanding of community resources, treatment options, home health, funding sources and special programs
- Ability to work independently with limited oversight
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.
