Care Management - Nurse, Senior

Blue Shield of CA; Phoenix (AZ); Hybrid; USD 105,000 - 125,000; Full time

Job summary

Blue Shield of CA is seeking a Senior Care Management Nurse to perform case management and develop care plans based on thorough assessments, coordinating with clinical nurses and treating physicians.

The role requires a California RN license, BSN or higher preferred, CCM certification, and 5+ years of healthcare experience with 3+ in managed care; hybrid virtual work with occasional office visits, PST business hours.

Qualifications

• CA RN license is required.
• BSN or higher preferred.
• CCM certification in process or achieved.
• At least 5 years of nursing/healthcare experience.
• At least 3 years of managed care experience.
• Ability to assess, interpret clinical information and plan care.
• Knowledge of Medicare regulations, prior authorization, level of care criteria.

Responsibilities

• Determine, develop and implement the plan of care based on accurate assessments.
• Collaborate with members, nurses, and treating physicians.
• Address chronic conditions, poly-pharmacy, prenatal care, and health assessments.
• Demonstrate independent clinical judgment and critical thinking in care planning.

Skills

CA RN License

5+ years healthcare experience

3+ years managed care

Clinical assessment & care planning

Knowledge of guidelines

Education

BSN or higher

CCM Certification

Tools

MS 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.