Care Management - Nurse, Senior

Blue Shield of CA; Los Angeles (CA); On-site; USD 90,000 - 110,000; Full time

Job summary

Blue Shield of California is seeking a Care Management professional to independently manage complex high-risk cases, apply clinical judgment to assess medical necessity, and develop cost-effective care plans in alignment with benefit requirements.

You will collaborate with providers and interdisciplinary teams, coordinate discharge planning, reassess plans, and participate in a rotating evening and weekend on-call schedule in a hybrid virtual work model.

Qualifications

• Ability to independently assess, evaluate, and interpret complex clinical information and care plans.
• Advanced knowledge of evidence based clinical practice guidelines, particularly for chronic conditions.
• Knowledge of community resources, home health services, funding sources, and specialty programs.
• Knowledge of regulatory and accreditation standards including CMS, DHCS, URAC, NCQA, DMHC, MHPAEA, and CA SB 855 is preferred.
• 3 years of managed care experience preferred

Responsibilities

• Collaborate with providers, medical directors, and interdisciplinary teams to coordinate care.
• Support discharge planning and evaluate barriers to care.
• Ensure members receive appropriate referrals and continuity of treatment.
• Ongoing reassessment of care plans and awareness of healthcare trends and guidelines.
• Participate in rotating evening and weekend on-call schedule.

Skills

Clinical assessment

Care coordination

On-call management

Regulatory knowledge

Evidence-based guidelines

Education

Associate Degree in Nursing

Bachelor of Science in Nursing

Job description

Your Role

The Care Management team independently manages complex and high-risk care management cases by applying advanced clinical judgment to assess medical necessity, develop cost-effective care plans, and support quality outcomes aligned with benefit and contract requirements. You will collaborate with providers, medical directors, and interdisciplinary teams to coordinate care, support discharge planning, evaluate barriers to care, and ensure members receive appropriate referrals and continuity of treatment. This position also requires ongoing reassessment of care plans, awareness of healthcare trends and clinical guidelines, and the ability to participate in a rotating evening and weekend on-call schedule.

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.

Your Knowledge and Experience

• Associate Degree in Nursing required or master's degree in relevant field for non-RN licensure.
• Bachelor of Science in Nursing is preferred
• 5 years of experience in nursing, healthcare, or a related clinical field
• 3 years of managed care experience preferred
• Certified Case Manager (CCM) is preferred
• Ability to independently assess, evaluate, and interpret complex clinical information and care plans
• Advanced knowledge of evidence based clinical practice guidelines, particularly for chronic conditions
• Demonstrated competence in care management functions and standards of practice
• Knowledge of community resources, treatment options, home health services, funding sources, and specialty programs
• Working knowledge of regulatory and accreditation standards including CMS, DHCS, URAC, NCQA, DMHC, MHPAEA, and CA SB 855 is preferred
• Knowledge of coordination of care, government and commercial regulations, prior authorization processes, and level of care and length of stay criteria is preferred

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.