Care Management - Nurse, Senior (FEP - Triage)

Blue Shield of CA; Lodi (CA); Hybrid; USD 95,000 - 115,000; Full time

Job summary

Blue Shield of California seeks a Complex Care Coordination Triage Registered Nurse Case Manager for the Federal Employee Program team. You will determine, develop, and implement a plan of care based on comprehensive member assessment, collaborating with care teams and physicians to support clinical judgment and cost-effective outcomes.

Hybrid virtual work model allows full-time remote duties with periodic office attendance based on business needs.

Qualifications

• Requires RN licensure in CA with active status.
• 5+ years of nursing, healthcare, or related field experience.
• Knowledge of case management, discharge planning, utilization management, disease management, and community resources.
• CCM certification preferred.
• Strong documentation and analytical skills.
• Ability to operate PC-based software including Word and Excel.
• Understanding of NCQA and federal regulatory requirements.

Responsibilities

• Assess members and develop plans of care based on comprehensive assessment.
• Coordinate with care teams and physicians to implement care plans.
• Document clinical decisions and maintain accurate records.
• Contribute to program evaluation and continuous improvement.
• Demonstrate leadership and communication with all organizational levels.

Skills

Clinical documentation

Problem solving

Verbal communication

Written communication

Negotiation

Leadership

Team collaboration

Education

Associate Degree in Nursing

BSN preferred

Tools

Microsoft Word

Microsoft Excel

Job description

Your Role

The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with the members' care including clinical nurses and treating physicians. The Complex Care Coordination Triage Registered Nurse Case Manager will report to the FEP Care Manager Department Manager. In this role you will determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the members' needs.

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 Nursingrequired
• Bachelor of Science in Nursing or advanced degree preferred
• Must maintain active, unrestricted RN in CA
• Requires at least 5 years of prior experience in nursing, healthcare or related field
• Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources
• Certified Case Manager (CCM) Certification is preferred
• Able to operate PC-based software programs including proficiency in Word and Excel.
• Strong clinical documentation skills, independent problem identification and resolution skills
• Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills
• Competent understanding of NCQA and federal regulatory requirements.
• Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable
• Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care
• Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making

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.