Your Role
The Federal Employee Program (FEP) Care Management team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis by collaborating with members and those involved with their care including a multidisciplinary team and the member's treating physicians. The Clinical Program Manager Consultant will report to the FEP Care Management Department Manager. In this role you will be responsible for supporting the overall FEP CM team as a subject matter expert while exemplifying BSC leadership behaviors.
Your Work
In this role, you will:
- Contribute to the adoption, evaluation, and ongoing improvement of CM electronic medical record (EMR). Participate in go-live testing which may occur afterhours or on weekends, based on the posted monthly release schedule.
- Work to achieve operational targets defined by the Blue Cross Blue Shield Association (BCBSA) by preparing and assisting with review and submission of Care Management data to the BCBSA.
- Create and educate the team on specifications around the Healthcare Effectiveness Data and Information Set (HEDIS) measures selected by Office of Personnel Management (OPM) and participate in outreach to members.
- Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards.
- Lead team huddles/meetings to support process changes and encourage collaboration of team members.
- Contribute to the development of goals for the department and planning efforts (budgets, operational plans, etc.). Influence the performance of the business unit in achieving Blue Shield of California's objectives. Responsible for collecting data required for contractual reporting.
- Responsible for auditing, providing guidance, coaching, training and precepting to other employees within job area. Collaborate with the training department and operation department to customize training specific to the FEP team. Prep cases for internal and external audits.
- Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD).
- 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.
- Design in collaboration with the HEDIS quality team, appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes.
Your Knowledge and Experience
- Typically, requires a college degree or equivalent experience and minimum 7 years of prior relevant experience.
- Clinical licensing or certification requirements may apply depending upon position. RN, OT, MSW, CPHQ Cert preferred.
- Certified Case Manager (CCM) Certification or qualifies to complete certification when eligible based on CCM application requirements preferred.
- Demonstrated ability to test EMR systems and guide the development of acceptance criteria statements to improve the EMR systems.
- Extensive knowledge of evidenced based clinical practice guidelines particularly for chronic conditions.
- Working knowledge of regulatory and accreditation standards preferred (NCQA, Case Management Society of America CMSA). Demonstrated and evolving competence in CM functions and standards of practice.
- Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable.
- Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
- Excellent analytical and problem-solving skills.
- Strong clinical documentation skills, independent problem identification and resolution skills. Proficiency with Microsoft applications including Word, Excel, Outlook, and Teams.
- Possesses cultural awareness to work effectively, respectfully, and sensitively within the client's cultural context.
- In depth understanding of community resources, treatment options, home health, funding sources and special programs.
- Ability to work independently with limited oversight.
Pay Range:
The pay range for this role is: $109120.00 to $163680.00 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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