Care Management - Nurse, Senior - Transplant

Blue Shield of California; Cameron Park (CA); Híbrido; USD 120.000 - 160.000; Jornada completa

Descripción de la vacante

Blue Shield of California in California seeks a Senior Case Management Nurse to assess and develop care plans, coordinating with members, nurses, and treating MDs. The position reports to the Manager, Care Management and emphasizes clinical judgment, evidence-based practice, and cost-effective care.

This hybrid virtual role requires CA RN licensure and an Associate’s Degree in Nursing; BSN preferred and CCM certification is a plus.

Formación

• Requires CA RN license and active licensure; compact state licensure preferred.
• Associate’s Degree in Nursing required; BSN or higher preferred.
• CCM Certification or in process when eligible per CCM requirements.
• Minimum 5 years of nursing/healthcare experience; prior transplant experience required.
• 3 years of managed care experience preferred.
• Able to assess, evaluate, and interpret clinical information for care planning.

Conocimientos

Critical thinking

Clinical judgment

Care planning

Microsoft Office 365

Educación

Associate’s Degree in Nursing

BSN or higher

Certified Case Manager (CCM) Certification

Herramientas

Microsoft Office 365

Descripción del empleo

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.

Our leadership model

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

• 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.