Case Management - Behavioral Health Nurse

Your Role

The Behavioral Health Registered Nurse Case Manager will report to the FEP 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.

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.

Your Work

In this role, you will :

Coordinates care for Lower Level of Care such as Residential Treatment, Partial Hospitalization Program, Intensive Outpatient Program, other outpatient services, and community programs as appropriate

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

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

Requires relevant behavioral health experience

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 : $ (phone number removed) to $ (phone number removed) 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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