Care Management - Nurse, Senior

Blue Shield of CA; Chicago (IL); Hybrid; USD 110,000 - 150,000; Full time

Job summary

Blue Shield of CA is seeking a Senior Care Management Nurse to assess and develop care plans, collaborating with members and treating clinicians. This role requires a CA RN license, CCM certification (or in progress), and at least 5 years in nursing or healthcare with 3+ years in managed care. The position supports care coordination and adherence to quality guidelines.

Hybrid virtual work is offered with occasional in-office requirements to support team collaboration and member care milestones.

Qualifications

• Requires a current CA RN License.
• Bachelor’s of Science in Nursing or advanced degree preferred.
• Certified CCM Certification or in process of completing certification when eligible based on CCM application requirements.
• Requires at least 5 years of prior experience in nursing, healthcare or related field.
• At least 3 years of managed care experience preferred.
• Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
• Extensive knowledge 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.
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets preferred.
• Able to operate PC-based software programs including proficiency in Microsoft Office 365 applications including Word, Excel, Outlook and Teams.

Responsibilities

• Determine, develop and implement the plan of care based on accurate assessment of the member and current or proposed treatment plan.
• Triage hub and manage cases involving chronic conditions, poly-pharmacy, prenatal care, and health assessments.
• Collaborate with members, clinical nurses and treating MDs to support care decisions.
• Maintain adherence to healthcare regulations and care coordination standards.

Skills

Clinical judgment

Independent analysis

Critical thinking

Case management

Education

BSN (Bachelor of Science in Nursing)

Advanced nursing degree

Tools

Microsoft Office 365

Job description

our Role

The Care Management team performs and case management (CM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members care including clinical nurses and treating MDs. The Care Management Nurse, Senior will report to the Manager, Care Management. In this role you will determine, develop and implement 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.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Please note that this position requires PST business hours.

Your Knowledge and Experience

• Requires a current CA RN License

• Bachelors of Science in Nursing or advanced degree preferred.

• Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements

• Requires at least 5 years of prior experience in nursing, healthcare or related field

• At least 3 years of managed care experience preferred

• Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
• Extensive knowledge 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.
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets preferred
• Able to operate PC-based software programs including proficiency in Microsoft Office 365 applications including Word, Excel, Outlook and Teams.

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.