Case Manager - Nurse, Senior (Behavioral Health)

Oakland, CA, United States

Job Description

Your Role

The Behavioral Health Registered Nurse Case Managerwill report to the FEP Department Manager. In this role you will determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the member's needs. The Federal Employee Program (FEP) team performs 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.

Your Work

In this role, you will:

Coordinates care for Lower Level of Care such as Residential Treatment, Partial Hospitalization Program, Intensive Outpatient Program, other outpatient services, and community programs as appropriate.

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

Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings

Applies 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

Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care

Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease)

Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs related to behavioral health

Must be able to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentation

Qualifications Requires a current CA RN License

Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements

Requires at least 5 years of prior experience in nursing, healthcare or related field

Bachelor of Science in Nursing or advanced degree preferred

Requires relevant behavioral health experience

Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources.

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

Demonstrates 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

Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making

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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About the Team

Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!

Our Values: Honest . We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.

Human . We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.

Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:

Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That's why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.

Two ways of working: Hybrid (our default) and office Hybrid - In a business unit approved office a few times per year to 3 days per week, on average

Office - In a business unit approved office 4+ days a week, on average. If the role you're applying for is deemed an "Essential Role," the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

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 regards 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.