Care Management - Nurse, Consultant

The Care Management team will serve to support the mission of the Population Health 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 act as a Care Management Lead ensuring that services are provided based on standardized procedures, including coordination of care with specialists and community resources. Care Managers on these teams perform a blended function of utilization management and care management activities demonstrating clinical judgement and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians. Responsibilities 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 Initiate timely individualized care plans (ICP) based on applicable assessments 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 review with medical groups or individual providers for continuity of care, out-of-area/out-of-network and investigational/experimental cases Assess members’ health behaviors, cultural influences, and clients belief/value system. Evaluate all information related to current/proposed treatment plan and 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 clients’ involvement Plan and design appropriate and fiscally responsible plan 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 Recognize need for contingency plans throughout the health care process Assume supervisor day-to-day responsibilities in manager’s absence and under the direction of the manager Analyze productivity and internal reports to ensure compliance Collaborate with department leadership to identify program development opportunities Mentor case managers with complex cases to promote quality of care, cost-effective health care services based on medical necessity and comply with contract for each appropriate plan type Perform precepting for new hires or those who are not meeting expectation Participate in special projects as needed Qualifications Current CA unrestricted RN License Bachelor of Science in Nursing or advanced degree preferred Certified Case Manager (CCM) Certification or 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 A minimum of 3+ years experience in inpatient, outpatient or managed care environment required Health insurance/managed care experience desired Transitions of care experience desired Excellent communication skills Hybrid Virtual Work This role allows employees to work virtually full-time; however, employees will be expected to come into the office based on business needs. Physical Requirements Office Environment – roles involving part to full time schedule in Office Environment. 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 regard 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. #J-18808-Ljbffr Blue Shield of California