Care Management - Nurse, Senior (FEP - Triage)

Blue Shield of CA; Long Beach (CA); Hybrid; USD 110,000 - 150,000; Full time

Job summary

Blue Shield of California is seeking a Complex Care Coordination Triage Registered Nurse Case Manager to assess members' needs, develop and implement plans of care, and coordinate with clinical nurses and treating physicians.

The role reports to the FEP Care Manager Department Manager and emphasizes leadership, clinical judgment, and continuous learning in a hybrid virtual work environment.

Qualifications

• Must maintain active, unrestricted RN license in California.
• Minimum 5 years of experience in nursing or healthcare.
• Knowledge of case management, discharge planning, utilization management and disease management.
• CCM certification preferred.
• Proficient in Word and Excel; strong documentation and communication skills.
• Ability to lead, supervise, negotiate and interact with senior management.

Responsibilities

• Determine, develop, and implement a plan of care based on assessments.
• Collaborate with members and care teams including nurses and physicians.
• Demonstrate clinical judgment and independent analysis.
• Contribute to leadership development and program evaluation.

Skills

Clinical leadership

Communication

Problem solving

Negotiation

Project management

Program evaluation

Education

Associate Degree in Nursing

Bachelor of Science in Nursing or advanced degree

CCM Certification

Tools

Word

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.