Your Role

The Children's Health Program (CHP) 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 CHP 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/ECM Eligibility guideline which align with nationally recognized standards. Responsible for managing member needs for specific CCS/EIES/DDS/CSHCN 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.

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/ECM 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