Job Description:

Business Unit: Health Care Quality & Affordability

The Health Care Quality and Affordability team is made up of about 1,000 doctors, nurses, pharmacists, strategists, industry experts and innovators with a single vision - to transform the delivery of health care. Every day, we work together to improve the quality of patient care for our members while lowering health Care costs to ensure all Californians have access to the care they deserve.

How do we do it? Through partnership, innovation, and thought leadership.

We continue to expand our network of providers to ensure state-wide access to care. We evaluate analytic and digital health tools that simplify care delivery while improving member health status, health care quality and affordability as well as member and provider experience. We provide high-touch services to members from experienced clinical teams. You'll also find us collaborating with our federal and state legislative officials to help shape policy to advance our Blue Shield mission.

Position Summary:

The Care Manager will report to the Manager of Care Management and 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. Case 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. The nurse care manager develops and implements the plan of care based on accurate assessment of the member using current or proposed treatment plan in cases of: member inquiry, triage hub, chronic conditions, poly-pharmacy, pre-natal care, and voluntary member health assessment, in addition to indication of multiple monthly ER visits. The CM applies detailed knowledge of Blue Shield of California (BSC) and Blue Shield Promise Health plan established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case. CM care typically lasts three months per member/patient. The care manager will reinforce pillars of care, that include but not limited to increasing quality of patient care and access while improving member satisfaction.

The senior RN Care Manager must have extensive background of the care management operations and a solid knowledge of community resources, best practices, and the promotion holistic and integrated high-tech and high-touch approach to medical care management. The selected candidate will also have knowledge of Medi-Cal regulations, processes for dual eligible members, Medi-Cal SPD, , and other programs and services.

The RN Care Manager will play a vital role in the MCS Maternity Program. The CM will be resourceful and empathic to the issues pertaining to SDOH and racial disparities.

Specific Responsibilities Include:

- Researches and designs 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 health risk assessment (HRA) completion, participation in and documentation of interdisciplinary meetings (ICT), assisting in transitions of care across all ages.

- Determines appropriateness of referral for CM services, mental health, and social services.

- Provides Referrals to other care management programs as needed.

- Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases.

- Manages member treatment to meet recommended length of stay and treatment plans. Ensures DC planning at levels of care appropriate for the members needs and acuity.

- 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.

- Researches 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 and Promise Health Plan.

- Determines realistic goals and objectives and provides appropriate alternatives. Actively solicits client's involvement.

- 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 or proposed treatment plan.

Specialty Areas:

- Experience and/or interest in Maternity, Women's & Children's Health, Perinatal, Postpartum, Obstetrics, High-Risk Obstetrics, NICU, or other related specialties.

- Strong clinical documentation skills, independent problem identification and resolution skills.

- Strong verbal and written communication and negotiation skills.

- Works on projects with minimal supervision.

- Demonstrates cultural competence to work effectively, respectfully, and sensitively within the client's cultural context.

- Mentors, trains, performs to QA audits, employee evaluations and performance assessments in partnership with CM Lead.

- Advocates understanding and respect for the beliefs, value system, and decisions of the client. Recognizes the clients right to self-determination as it relates to the ethical principle of autonomy, including the client/family right to make informed choices that may not promote the best outcomes, as determined by the healthcare team.

- Demonstrates cultural competence to work effectively, respectfully, and sensitively within the client's cultural context.

- Assists with precepting responsibilities for new hires and auditing efforts.

Minimum Education & Experience Requirements:

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A minimum of a bachelor's degree in Nursing (BSN)from a regionally accredited college or university or associate degree in Nursing (ADN) and a bachelor's degree in a different field.

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A minimum of 3 years' experience in inpatient, outpatient, or managed care environment.

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A minimum of 5 years' combined experience in clinical nursing practice in the hospital, outpatient, or managed care setting.

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Licensure as a Registered Nurse (RN)

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Certified Case Manager (CCM) or related board certification from a nationally recognized entity, i.e.

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.

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