Case Management - LVN, Senior - Blue Shield of California : Job Details

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 LVN -Consultant 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 -CCS/EIES/ DDS/CSHCN/EPSDT 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 case management and care coordination, and ensuring compliance performance metrics are met. -In addition, the CM LVN Consultant -will -assist -the -CSP -Managers -in -improving -operational -processes -and -implementation of new regulatory requirements. They would also assist in training and developing CSP staffs performance. Your -Work In -this role, -you will:

• Perform -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.
• Conducts clinical -review -of claims -for -medical -necessity, -coding -accuracy, -medical policy compliance and contract compliance
• Ensure -discharge -(DC) -planning -at -levels -of -care -appropriate -for -the -members -needs and -acuity -and -determine -post-acute -needs -of -member -including -levels of -care, durable medical -equipment, -and -post service needs -to ensure quality -and cost- appropriate DC planning
• Prepare and -present -cases -to -Medical -Director -(MD) for -medical -director -oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements
• Develop -and -review -member -centered -documentation -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.
• Develops and reviews member centered documentation and correspondence reflecting -determinations in -compliance -with -regulatory and -accreditation -standards.
• Identifies potential quality of care issues, service or treatment delays and intervenes or -as -clinically appropriate -and -provide -care -coordination -to -identified -CHP -members.
• Provides referrals to Social Services, Behavioral -Health, -Appeals -and -Grievance, -and -Quality -Departments -as -necessary. -In addition -to -collaboration -with -County -CCS -and -Regional -Centers. -In -addition, -the -CM LVN Consultant will assist the CSP Managers in improving operational processes and implementation -of -new -regulatory -requirements. -They -would -also -assist -in -training -and developing CSP staff's performance. Your -Knowledge -and -Experience
  • Requires -a bachelor's -degree or equivalent -experience
  • Requires -a -current -California -LVN -License -
  • Requires at least -7 years -of -prior -relevant -experience
  • A -minimum of 4 -years' -experience -in Medi-Cal -Clinical -Review, Case -Management -and Care Coordination. -
  • A -minimum of 2 -years' -experience -with Child -Health -Programs -[CCS, -EI,ES, DDS, EPSDT, CHDP preferred]
  • Demonstrated -knowledge -of -CMS -/ -DHCS -protocols -and requirements
  • Demonstrated -understanding -of -NCQA -/ -CMS -/ -DHCS -regulatory -audit -requirements
  • Care -Coordination -and -Case -Management -experience - Pay Range: The pay range for this role is: $ 77990.00 to $ 116930.00 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. #LI-MM4