Case Management – Nurse, Senior

Your Role

The Case Manager will report to the Manager of Case Management and is responsible for the coordination of care and services on behalf of Members of Blue Shield of California. The Case Manager effectively collaborates directly with the Member, Member’s Family, and Interdisciplinary Care Team to achieve consensus and promote positive Member health outcomes through the assessment, planning, implementation, and evaluation of the Member’s Care Plan. The Case Manager identifies gaps in care and coordinates the available resources required to meet the Member’s health care needs through clear communication and advocacy that aims to promote quality cost-effective interventions based on medical necessity and compliance with the Member’s Health Plan.

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 the contract for each appropriate plan type.
• Collaborate with the interdisciplinary healthcare team to help reduce hospital re-admissions and ensure members receive timely preventive care and screening tests.
• Coordinates care for specific high risk patient population, including referrals to community resources, facilitation of medical services, referral to ancillary providers, etc.
• 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
• Strong written and verbal communication skills with ability to advocate and negotiate on behalf of the Member. Bilingual preferred.
• Strong clinical documentation skills, independent problem identification and resolution skills.
• Ability to work with minimal supervision within the company and with external partners and demonstrate professional judgment and critical thinking when advocating for medical necessity that promotes quality, cost-effective care.
• Demonstrates cultural competence and understanding and respect for the beliefs, value systems, and decisions of the Member.
• Understanding of the Member’s right to self-determination as it relates to the ethical principle of autonomy.
• Proficient in software programs including Microsoft Office (Word/Outlook/Excel). 
• Works with Members and their families to understand the illness or injury and collaborates with the Member’s healthcare team to develop individualized care plans with healthcare goals that aim to produce the best health outcomes for the Member.
• Develops and implements Member centric interventions based on accurate assessments of the Member’s physical, functional, behavioral, and social needs, and current or proposed treatment plans in accordance with evidence based and clinical practice guidelines.
• Demonstrates sound clinical judgement and independent analysis to identify and navigate barriers that may prevent Members from achieving their healthcare goals.
• Applies detailed knowledge of Blue Shield’s established medical and departmental policies, clinical practice guidelines, community resources, and contractual and community care standards.
• Works with medical groups and individual providers to ensure continuity of care and implement effective discharge planning activities appropriate for the member’s needs.