Your Role
The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with the members' care including clinical nurses and treating physicians. The Complex Care Coordination Triage Registered Nurse Case Manager will report to the FEP Care Manager Department Manager. In this role you will determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the members' needs.
Your Work
In this role, you will
- Conduct provider searches and assists members in accessing medically necessary services within the access network and plan benefits
- Triage referrals coming from the 24-hours Nurse Line to ensure members see providers in timely fashion and receive necessary education on their health conditions
- Work with providers and other internal departments to initiate the Letter of Agreement (LOA) and Exception process
- Provide disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease) and rare conditions
- Outreach to members with HEDIS Care Gaps to assist with closure
- Perform effective discharge planning and collaborate with member support system and health care professionals involved in the continuum of care
- Coordinate transition to lower level of care such as skilled nursing facility, home health, home infusion, acute rehab, and other community program as appropriate
- Recognize the client's right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
- Apply detailed knowledge of FEP PPO and Blue Shield of California's (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case
- Identify and report potential quality of care issues to Quality Management and Appeals & Grievance Departments
- Develop individualized care plans based on each member's medical and behavioral health needs, covered benefits, and available services.
- Review and update care plans as members' needs evolve to promote quality, accessible, and cost-effective care.
- Must be able to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentation