Care Managers perform 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. Care Managers determine, develop and implement a plan of care based on accurate and comprehensive assessment of the members needs. Care Managers apply detailed knowledge of Blue Shield of California (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case. Responsibilities:Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the members needs. Applies detailed knowledge of FEP PPO and Blue Shield of Californias (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case. Works with complex cases, promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits.Provides guidance to the provider network.Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care.Coordinates Care for Lower Level of Care coordination such as Skilled Nursing Facility, Residential Treatment Center, Home Health, Home Infusion, RehabProvides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease).Makes referrals to Quality Management, Catastrophic Case Management and Appeals and Grievance Department.Additional Skills: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. Solid case preparationDemonstrated leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making.
