YourRole
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 ClinicalTeam.The CaseManagement LVNConsultant willreporttotheCSPManager.Inthisrole you will be perform clinical review, assessment, evaluation of medical services for the organizationusingtheestablishedandapprovedBlueShieldMedicalPolicies andCCS/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 ConsultantwillassisttheCSPManagersinimprovingoperationalprocessesandimplementation of new regulatory requirements. They would also assist in training and developing CSP staffs performance.
YourWork
Inthis role,you will:
- PerformCare Management/Care Coordination formembers usingBSCevidenced 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 clinicalreviewof claimsformedicalnecessity,codingaccuracy,medical policy compliance and contract compliance
- Ensuredischarge(DC)planningatlevelsofcareappropriateforthemembersneeds andacuityanddeterminepost-acuteneedsofmemberincludinglevels ofcare, durable medicalequipment,andpost service needsto ensure qualityand cost- appropriate DC planning
- Prepare andpresentcasestoMedicalDirector(MD) formedicaldirectoroversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements
- Developandreviewmembercentereddocumentationandcorrespondencereflecting determinations in compliance with regulatory and accreditation standards andidentify potentialqualityof care issues,serviceortreatmentdelays andintervenes or as clinically appropriate
- Preparesandpresents cases toMedicalDirector(MD)formedicaldirectoroversight and CCS eligibility determination.
- Communicatedeterminationstoprovidersand/ormemberstoincompliancewith state, federal and accreditation requirements.
- Develops and reviews member centered documentation and correspondence reflectingdeterminations incompliancewithregulatory andaccreditationstandards.
- Identifies potential quality of care issues, service or treatment delays and intervenes orasclinically appropriateandprovidecarecoordinationtoidentifiedCHPmembers.
- Provides referrals to Social Services, BehavioralHealth,AppealsandGrievance,andQualityDepartmentsasnecessary.In additiontocollaborationwithCountyCCSandRegionalCenters.Inaddition,theCM LVN Consultant will assist the CSP Managers in improving operational processes and implementationofnewregulatoryrequirements.Theywouldalsoassistintrainingand developing CSP staff’s performance.
YourKnowledgeandExperience
- Requiresa bachelor'sdegree or equivalentexperience
- RequiresacurrentCaliforniaLVNLicense
- Requires at least7 yearsofpriorrelevantexperience
- Aminimum of 4years'experiencein Medi-CalClinicalReview, CaseManagementand Care Coordination.
- Aminimum of 2years'experiencewith ChildHealthPrograms[CCS,EI,ES, DDS, EPSDT, CHDP preferred]
- DemonstratedknowledgeofCMS/DHCSprotocolsand requirements
- DemonstratedunderstandingofNCQA/CMS/DHCSregulatoryauditrequirements
- CareCoordinationandCaseManagementexperience
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.
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