Care Management - Nurse, Senior

Blue Shield of CA; Houston (TX); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of California is seeking a Care Management Nurse, Senior to lead assessments, develop plans of care, and coordinate with members, clinical nurses, and treating MDs. The role reports to the Manager, Care Management and addresses complex cases including chronic conditions and polypharmacy.

This position requires CA RN license; CCM certification preferred; 5+ years nursing/healthcare experience with 3+ years in managed care.

Qualifications

• Requires a current CA RN License.
• Bachelors of Science in Nursing or advanced degree preferred.
• CCM Certification or in process of completing certification when eligible.
• At least 5 years of prior experience in nursing, healthcare or related field.
• At least 3 years of managed care experience preferred.
• Ability to independently assess, evaluate and interpret clinical information and care planning.
• Knowledge of evidence-based clinical practice guidelines for chronic conditions.
• Judgement and critical thinking to determine medical necessity and cost-effective care.
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and LOS criteria.
• Proficient with PC-based software incl. Word, Excel, Outlook and Teams.

Responsibilities

• Determine, develop and implement the plan of care based on assessment and treatment plans.
• Collaborate with members, clinical nurses and treating MDs.
• Address complex cases including chronic conditions, poly-pharmacy, prenatal care and health assessments.
• Apply professional judgment and evidence-based guidelines to support medical necessity.

Skills

Clinical judgment

Independent analysis

Critical thinking

Team collaboration

Education

Bachelor of Science in Nursing

Advanced degree (MSN or higher)

Certified Case Manager (CCM) Certification

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.