Care Management - Nurse, Senior - Transplant

Blue Shield of California

California

Hybrid

USD 91,000 - 136,000

Full time

14 days+

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Job summary

Blue Shield of California seeks a Senior Case Management Nurse to lead complex case management, collaborate with clinical staff, and develop comprehensive care plans for members with chronic conditions and multiple ER visits. The role reports to the Manager, Care Management and emphasizes clinical judgment, cost-effective care, and continuous improvement.

The hybrid role requires strong nursing credentials (CA RN) and at least 5 years of healthcare experience, with CCM certification preferred

Qualifications

Requires CA RN license (active) or license from another state.
Associate’s Degree in Nursing; BSN preferred.
CCM Certification or in process of completing certification when eligible.
At least 5 years of prior nursing/healthcare experience.
Prior transplant experience is required.
3 years of managed care experience preferred.
Strong ability to assess, evaluate, and interpret clinical information for care planning.
Proficient with Office 365 (Word, Excel, Outlook, Teams).

Responsibilities

Research and design treatment/care plans to promote quality of care and cost-effective services.
Provide referrals to QM, DM, and AGD departments.
Honor patient autonomy and informed decision-making in care planning.
Design appropriate and fiscally responsible plans of care with targeted interventions.
Initiate modifications in plans as conditions change over time.
Conduct member care reviews with medical groups or providers.
Assess health behaviors and cultural influences; identify barriers.
Promote continuous improvement and adherence to guidelines.

Skills

Nursing

Clinical judgment

Care planning

Care coordination

Research

Leadership

Communication

Education

Associate's Degree in Nursing

Bachelor of Science in Nursing

CCM Certification

Tools

Microsoft Office 365

Job description

Your Role

The Case Management team performs 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 Case 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.

Job Description

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.

Responsibilities

In this role, you will:

Research and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type
Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)
Recognize the member’s right to self-determination as it relates to the ethical principle of autonomy, including the member/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
Prior transplant experience is preferred
Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes
Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings
Conduct member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases
Assess members’ health behaviors, cultural influences and members’ belief/value system. Evaluates all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers. Research opportunities for improvement in assessment methodology and actively promote continuous improvement.
Anticipate potential barriers while establishing realistic goals to ensure success for the member, providers and BSC
Planning: Designs appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes
Adjust plans or creates contingency plans as necessary
Assess and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settings
Develop appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes

Qualifications

Your Knowledge and Experience

Requires a current and valid CA RN License or valid RN license(s) from other state(s). Preferred licensure from a compact state. If assigned to another state, must maintain an active, unrestricted RN license in assigned state(s) or the ability to obtain required RN license (in addition to primary state license) within 90 days of hire
Requires an Associate’s Degree in Nursing
Bachelor 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
Prior transplant experience is required
Desired 3 years of managed care experience
Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning
Extensive knowledge of evidence 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 desirable
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.

About Us

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

About Blue Shield of California

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!

Our Values:

Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

For most teams, this means coming into the office two days per week.
Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

Pay Range for California : $90860.00 to $136290.00

Pay Range for Bay Area : $102424.00 to $153636.00

Role can be filled by a candidate requiring sponsorship : No

Job Schedule : Full time

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