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

Your 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 be 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 align with nationally recognized standards. Responsible for managing member needs for specific CCS/EIES/DDS/CSHCN/EPSDT and other clinical programs and care coordination. Responsible in assisting and working daily inventory, providing high-quality clinical reviews, performing efficient care management and care coordination, and ensuring compliance performance metrics are met.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Knowledge and Experience

• 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

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.

Your Work

In this role, you will:

• 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 Eligibility guidelines.
• 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
• Prepares and presents 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. In addition to collaboration with County CCS and Regional Center

Your Work

In this role, you will:

• 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 Eligibility guidelines.
• 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
• Prepares and presents 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. In addition to collaboration with County CCS and Regional Center