Care Management - Nurse, Senior

Blue Shield of CA; Washington (District of Columbia); Hybrid; USD 110,000 - 140,000; Full time

Benefits offered by this job

Hybrid Virtual Work

Job summary

Blue Shield of California seeks a Care Management Nurse, Senior to perform case management, determine and implement care plans, and collaborate with members and clinicians. You will assess needs, coordinate with nurses and treating MDs, and apply clinical judgment for complex cases including chronic conditions and poly-pharmacy.

The role requires a CA RN license, a BSN or higher preferred, CCM certification or progress, and 5+ years in nursing with 3+ years in managed care.

Qualifications

• CA RN license required and must be in good standing.
• CCM certification preferred or in progress.
• Minimum 5 years in nursing, healthcare, or related field.
• At least 3 years in managed care preferred.
• Proficient with Microsoft Office 365 applications.

Responsibilities

• Determine, develop and implement the plan of care based on assessment and treatment plan.
• Collaborate with members, nurses, and treating MDs to support member care.
• Assess, evaluate and interpret clinical information for care planning.
• Apply evidence-based guidelines to promote quality and cost-effective care.

Skills

CA RN License

Bachelors in Nursing

CCM Certification

Clinical assessment

Managed care experience

Critical thinking

MS Office 365

Education

BSN or higher

Tools

Word

Excel

Outlook

Teams

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.