Case Management - Nurse, Senior

Your Role

The Care Management team coordinates, educates, and advocates care for the Dual-Special Needs (DSNP) population with Blue Shield of California. The Case Management – Nurse, Senior will report to the Manager of Care Management within Medical Care Solutions. In this role you will be responsible for managing a caseload of DSNP members, reviewing Health Risk Assessments and completing Individualized Care Plans, engaging with members to reduce readmissions to the hospital, and supporting the DSNP care management team.

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
• Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings
• Review Health Risk Assessments and create Individualized Care Plans for each member on your caseload
• Educate, advocate, and coordinate care for members for improved quality of life and reduced health complications
• Engage with members for Transition of Care program processes to help reduce health complications and hospital readmissions after recent discharges
• Work closely with an Interdisciplinary Team to engage members, improve access to care, and reduce barriers to care
  

Your Knowledge and Experience

• Current CA RN License
• Bachelor of Science degree in Nursing or advanced degree preferred
• Certified Case Manager (CCM) or is in process of completing certification when eligible based on CCM application requirements or National Certification in related field
• Requires 5+ years experience in nursing, healthcare or related field
• Understanding of Interdisciplinary Team dynamics
• Understanding and experience with Motivational Interviewing techniques
• Experience managing care for patients and coordinating with different disciplines