Care Management - Nurse, Senior

Blue Shield of CA; Virginia Beach (VA); Hybrid; USD 90,000 - 130,000; Full time

Job summary

Blue Shield of CA is seeking a Senior Care Management Nurse to lead case management activities with strong clinical judgment and independent analysis. You will assess members, determine plans of care, and coordinate with nurses and treating physicians to support optimal outcomes.

A CA RN license and CCM certification are preferred, with 5+ years in nursing or healthcare and 3+ years in managed care. The role emphasizes evidence-based guidelines, coordination of care, and the use of MS Office 365

Qualifications

• Requires current CA RN License.
• BSN or higher degree preferred.
• CCM Certification in progress or achieved when eligible.
• At least 5 years of nursing, healthcare, or related experience required.
• At least 3 years of managed care experience preferred.
• Ability to assess, evaluate, and interpret clinical information and care planning.

Responsibilities

• Perform and conduct care management activities with clinical judgment and independent analysis.
• Develop and implement plans of care based on accurate assessments and current treatment plans.
• Collaborate with members, family, clinical nurses, and treating physicians to coordinate care.
• Assess medical necessity and apply evidence-based guidelines for chronic conditions.
• Utilize PC-based software and MS Office 365 for documentation and communication.

Skills

Clinical judgment

Independent analysis

Care planning

Critical thinking

Communication

Education

BSN

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.