Case Management - Nurse, Senior

YourRole

The Childrens Health Program (CHP) team provides identification, referrals, and care management for all Medi-Cal members under 21 years old and collaborates within Promise Clinical Team. The Case Management Nurse, Senior will report to the CHP Manager. In this role you will be Perform clinical review, assessment, evaluation ofmedical services for the organization using the established and approved Blue Shield Medical Policies and CCS/EIES/DDS/ECM Eligibility guideline which align with nationally recognized standards. Responsible for managing member needs for specificCCS/EIES/DDS/CSHCN and other clinical programs and care coordination.Responsible in assisting and working daily inventory, providing high-quality clinical reviews, performing efficient care management and care coordination, and ensuring compliance performance metrics are met.

YourWork

Inthisrole,youwill:

• Performcare management/care coordination for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines ofbusiness or for a specific line of business such as Medi-Cal and CCS/EIES/DDS/ECM Eligibility guidelines.
• Conductsclinicalreviewof claims formedicalnecessity,codingaccuracy,medical policy compliance and contract compliance
• Ensure discharge (DC) planning at levels ofcare appropriate for the members needs and acuity anddeterminepost-acuteneedsof member including levels ofcare, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning
• Prepareand present cases to Medical Director (MD) for medical director oversight and necessitydetermination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standardsand identifypotentialqualityof careissues,serviceortreatment delays and intervenes or as clinically appropriate
• PreparesandpresentscasestoMedicalDirector(MD) formedicaldirectoroversightand CCS eligibilitydetermination.
• Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
• Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
• Identifiespotential quality ofcare issues, service or treatment delays and intervenes or as clinically appropriateand provide care coordination to identified CHP members.
• Provides referrals to Social Services, Behavioral Health, Appeals and Grievance, and Quality Departments as necessary. In addition to collaboration with County CCS and Regional Centers

YourKnowledgeandExperience

• Current CA RN License
• BachelorsofScienceinNursingoradvanceddegreepreferred
• Certified Case Manager (CCM) or is in process of completing certification when eligible based on CCM application requirements or National Certification in related field
• Requiresatleast5yearsofpriorrelevantexperience
• 4 years experience in Medi-Cal Clinical Review, Case Management and Care Coordination preferred
• 2 years experience in Pediatrics withChildren's Health Programs (EI, ES, DDS, EPSDT, CHDP ) preferred
• Workingknowledge ofregulatory and accreditationstandards (URAC, NCQA, DMHC, Case Management Society of America CMSA) preferred
• CareCoordinationandCaseManagementexperiencepreferred

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.

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