Job Description

Your Role

Work schedule is Mon-Fri 10am- 7pm

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. The Regional Registered Nurse Case Manager will report to the FEP Care Management 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

Your Work

In this role, you will:

• Coordinate care for lower level of care such Skilled Nursing Facility, Home Health, Home Infusion, Acute Rehab, Long-term Acute Care Hospital, Hospice, and other community program as appropriate
• Perform effective discharge planning and collaborate with member’s 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). Outreach to members with HEDIS Care Gaps to assist with closure
• Apply detailed knowledge of FEP PPO and Blue Shield of California's established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case
• 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 
• 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. 
• Bachelor 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 5 years of prior experience in nursing, healthcare or related field
• 3+ years managed care experience preferred.
• Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources preferred
• Behavioral health, oncology, or OB/NICU/pediatrics experience preferred
• Strong electronic clinical documentation skills, independent problem identification and resolution skills
• Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable
• Competent understanding of NCQA and federal regulatory requirements
• Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making
• 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

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