Care Management - Nurse, Senior (FEP - Triage)

Blue Shield of CA; Springfield Meadows (CA); Hybrid; USD 100,000 - 140,000; Full time

Job summary

Blue Shield of California's Federal Employee Program (FEP) team is seeking a Complex Care Coordination Triage Registered Nurse Case Manager to lead integrated case and disease management efforts. You will assess members, develop care plans, and collaborate with nurses and treating physicians to ensure high-quality, cost-effective care.

Reporting to the FEP Care Manager Department Manager, you will apply clinical judgment, NCQA and federal regulatory requirements, and strong communication skills

Qualifications

• Nurse with active, unrestricted RN license in CA.
• Minimum 5 years' experience in nursing, healthcare, or related field.
• Knowledge of case management, discharge planning, utilization management and disease management.

Responsibilities

• Determine, develop, and implement a plan of care based on comprehensive assessment.
• Collaborate with members and care team including clinical nurses and treating physicians.
• Demonstrate clinical judgment and independent analysis.
• Apply NCQA and federal regulatory requirements in care coordination.

Skills

Supervisory skills

Communication skills

Verbal & written communication

Negotiation skills

Clinical documentation

Problem identification & resolution

Regulatory knowledge

Leadership

Project management

Education

Associate Degree in Nursing

BSN or advanced degree preferred

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.