Care Management - Nurse, Senior (CA Children's Services)

About the role

The Children’s Services Program (CSP) team provides identification, referrals, and care management for all Medi-Cal members under 21 years old and collaborates within Promise Clinical Team. The Case Management Nurse, Senior will report to the CSP Manager. In this role, you will perform clinical review, assessment, evaluation of medical services for the organization using the established and approved Blue Shield Medical Policies and California Children’s Services (CCS), Early Intervention-Early Start (EIES), Developmental Disability Services (DDS), Children with Special Healthcare Needs (CSHCN), Early Periodic Screening Diagnostic Treatment (EPSDT) services Eligibility guideline which aligns with nationally recognized standards. You will manage member needs for specific CCS/EIES/DDS/CSHCN/EPSDT and other clinical programs and care coordination. You will assist and work daily inventory, providing high-quality clinical reviews, performing efficient care management and care coordination, and ensuring compliance performance metrics are met.

Responsibilities

• Perform complex care management/care management/care coordination for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medi-Cal and CCS/EIES/DDS/CSHCN/EPSDT
• Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members in compliance with state, federal and accreditation requirements
• Develop and review member centered care plans and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
• Prepare and present cases to Medical Director (MD) for medical director oversight and CCS eligibility determination. Communicate determinations to providers and/or members to in compliance with state, federal, and accreditation requirements. Identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate and provide care coordination to identified CSP members
• Provide referrals to Social Services, Behavioral Health, Appeals and Grievance, and Quality Departments as necessary

Qualifications

• Absolutely requires a current CA RN License
• Bachelor of Science in Nursing or advanced degree preferred
• Certified Case Manager (CCM) through the Commission for Case Manager Certification or is in process of completing certification when eligible based on CCM application requirements or National Certification in related field is preferred
• Requires at least 5 years of prior relevant experience including 4 years’ experience in Medi-Cal Clinical Review, Case Management and Care Coordination preferred
• 2 years’ experience in Pediatrics with Children's Health Programs (EI, ES, DDS, EPSDT, CHDP) specifically California Children’s Services (CCS) preferred
• Working knowledge of regulatory and accreditation standards (URAC, NCQA, DMHC, Case Management Society of America CMSA) preferred
• Care Coordination and Case Management experience strongly preferred

Benefits

Hybrid Virtual Work: This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

Pay

Pay Range for California: $90,860.00 to $136,290.00
Pay Range for Bay Area: $102,424.00 to $153,636.00

Schedule

Full time

Locations

• Long Beach, CA, United States
• El Dorado Hills, CA, United States
• Lodi, CA, United States
• Oakland, CA, United States
• Rancho Cordova, CA, United States
• Redding, CA, United States
• San Diego, CA, United States
• Woodland Hills, CA, United States