Your Role

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. The Triage Registered Nurse Case Manager will report to the FEP Care Manager 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.

Your Work

In this role, you will:

• Conduct provider searches and assist members in accessing medically necessary services within the access network
• Triage referrals coming from the 24-hours Nurse Line to ensure members see providers in timely fashion and receive necessary education on their health conditions
• Work with providers and other internal departments to initiate the Letter of Agreement (LOA) and Exception process
• Outreach to member's with HEDIS Care Gaps to assist with closure
• 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.
• Coordinates Care for Lower Level of Care coordination such as Skilled Nursing Facility, Home Health, Home Infusion, Rehab, and other community program as appropriate.
• 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

Your Knowledge and Experience

• 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
• 3+ years managed care experience preferred
• Bachelor of Science in Nursing or advanced degree preferred
• 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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