Case Management - Nurse, Consultant

Company: Blue Shield of California
Location: Rancho Cordova
Posted on: May 2, 2025

Job Description:

Your Role The Care Management team will serve to support the mission of the 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 ensure that services are provided based on standardized procedures including coordination of care with specialists, community resources. Care Managers perform a blended function of utilization management (UM) and care management (CM) activities demonstrating clinical judgement 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:

• 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.
• Initiation of timely individualized care plans (ICP) based on applicable assessments and assisting in transitions of care across all ages.
• Determines appropriateness of referral for CM services, mental health, and social services.
• Provides Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD).
• Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases.
• Assessment: Assesses members health behaviors, cultural influences, and clients belief/value system. Evaluates 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 promotes continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSC.
• Determines realistic goals and objectives and provides appropriate alternatives. Actively solicits client's involvement.
• Planning: Designs appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjusts plans or creates contingency plans as necessary.
• Assesses and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settings.
• Develops appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
• Recognizes need for contingency plans throughout the healthcare process.
• Develops and implements the plan of care based on accurate assessment of the member and current of proposed treatment.
• Assumes supervisor day to day responsibilities in manager's absence and under the direction of the manager
• Analyze productivity and internal reports to ensure compliance.
• Collaborates with department leadership to identify program development opportunities.
• Mentors case managers with complex cases to promote quality of care, cost effective health care services based on medical necessity and complies with contract for each appropriate plan type
• Performs precepting for new hires or those who are not meeting expectation.
• Participates in special projects as needed Your Knowledge and Experience
  • Current CA RN License.
  • Bachelors of Science in Nursing or advanced degree preferred.
  • Certified Case Manager (CCM) Certification or is 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+ year experience in inpatient, outpatient or managed care environment required
  • Health insurance/managed care experience desired.
  • Transitions of care experience desired
  • Excellent communications skills

Keywords: Blue Shield of California, Ceres , Case Management - Nurse, Consultant, Professions , Rancho Cordova, California