Health Advocate
Location: San Francisco California
Description: Blue Shield of California is currently seeking to employ Health Advocate right now, this occupation will be placed in California. For detail informations about this occupation opportunity please read the description below. Come join the hardest working, not-for-profit health plan in California and help deliver our mission to ensure all Californians have access to high-quality health care at an a! ffordable price. Blue Shield of California was founded in 1939 by a group of physicians who believed that everyone should be able to afford a visit to their doctor. More than 70 years later, Blue Shield now serves 3.3 million members, and is the first health plan in the nation to limit our annual net income to 2 percent of revenue and pledge to return the difference to our customers and the community with the board of directors' approval. We returned more than $475 million in 2011. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution. In 2012, we were named one of the World's Most Ethical Companies . Since 2005, the company has contributed more than $170 million to the Blue Shield of California Foundation, one of BusinessWeek's most generous corporate foundations .
Job Details
Position Summary:
! Case Managers perform a blended function of utilization manage! ment (UM) and case management (CM) activities demonstrating clinical judgement and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating MDs. Determines develops and implements the plan of care based on accurate assessment of the member and current or proposed treatment plan in cases of: member inquiry, triage hub, chronic conditions, poly-pharmacy, pre-natal care, and voluntary member health assessment, in addition to indication of multiple monthly ER visits. Apply detailed knowledge of Blue Shield of California (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case. CM care typically lasts three months per member/patient. Requires RN license and CM Certification at all levels. All levels require >80% Inter-Rater Reliability ratings, which test knowledge and skills based on hypothetical situations.
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Responsibilities:
- Provides guidance to the provider network
- Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care
- Coordinates Care for Lower Level of Care coordination such as Skilled Nursing Facility, Home Health, Home Infusion, Rehab.
- Makes referrals to Quality Management, Disease Management, Catastrophic Case Management and Appeals and Grievance Department
- Researches and designs 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
- Implements discharge (DC) planning activities for medically complex cases
- Determines appropriateness of referral for CM services
- Conducts member care review with medical groups or individual providers for continuity of care, out of area/out of network and! investigational/experimental cases
- Manages member treatment i! n order to meet recommended length of stay. Ensures DC planning at levels of care appropriate for the members needs and acuity
- Negotiates with employer groups when contractually required
- Assists Lead RN Case Manager with precepting and special projects
- Performs advanced or complicated case review and determines first level approvals for prior authorization of services, inpatient, outpatient and/or ancillary services
- The review process requires interpretation and application of evidenced based criteria as established by Blue Shield of California (BSC) medical policy and other approved resources
- Clinical judgment and detailed knowledge of benefit plans used to complete review decisions
- Acts as liaison between the member, the provider and the health plan to utilize appropriate and cost effective resources
- Ultimate goal is Discharge (DC) planning and to return ! patient to cognitive and physical condition prior to event that triggered treatment
- Prepares and presents cases to Medical Director (MD) as required by law for medical necessity determination
- Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements
1. This position will physically be located on the Stanford University campus.
2. The onsite Health Advocate will engage in face to face meetings with BSC Stanford members.
3. Provide health counseling and education for members.
4. Provide some limited health screenings such as blood pressure checks or weights.
5. The BSC Stanford Health Advocate will play a key role in int! erfacing with the Stanford AICU (Ambulatory Intensive Care Unit).
6! . Guide members to the most appropriate settings and levels of care.
7. Work with members who have the EPO to understand the network and assist with channeling efforts.
8. Participate in on site Stanford events as appropriate (e. g, health fairs, lifestyle management lunch and learns, etc)
9. Applicants must be passionate about "wellness"
10. Must like face-to-face contact with people/members
Job Required Education/Experience
Qualifications:
- Current CA RN License. Bachelors of Science in Nursing or advanced degree preferred
- Certified Case Manager (CCM) or is in process of completing certification when eligible based on CCM application requirements
- Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning
- In depth understanding of community resources, treatment options, home health, funding sources and special programs
- Extensive knowled! ge of evidenced based clinical practice guidelines particularly for chronic conditions
- Incorporates professional judgment and critical thinking when determining medical necessity that promotes quality, cost-effective care
- Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, Case Management Society of America CMSA)
- Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable
- Strong clinical documentation skills, independent problem identification and resolution skills
- Strong verbal and written communication and negotiation skills
- Ability to work on projects with moderate supervision
- Possesses cultural awareness to work effectively, respectfully, and sensitively within the clients cultural context
Recognizes need for contingency plans throughout the healthcare process.
Develops and implements the plan of care based on accurate assessment of the member and current or proposed treatment plan.
Additional Transplant CM Duties:
Provides clinical input to medical directors.
Conducts assessment and quality reviews of the BSC transplant network
Current knowledge of transplant service trends.
Minimum Experience Level:
- Generally requires moderate to extensive experience in nursing, health care or related field. Requires extensive experience in nursing, health care or related field. (5-7 years) . 3+ yrs managed care experience preferred.
- Monitors Clinical Support Coordinators (non-clinical) in the performance of UM support activities
- QA and regular performance audits.
- Training and mentoring as
- Backup to Lead as needed.
Blue Shield of California is committed to remaining a drug-free work place. All positions require a pre-employment background investigation and drug screen. Blue Shield of California is an Equal Opportunity Employer.
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If you were eligible to this occupation, please email us your resume, with salary requirements and a resume to Blue Shield of California.
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This occupation starts available on: Tue, 06 Aug 2013 05:21:17 GMT