Care Management - Nurse, Senior - Transplant

Blue Shield of CA; Hartford (CT); Hybrid; USD 95,000 - 130,000; Full time

Job summary

The Case Management Nurse, Senior at Blue Shield of CA will lead case management activities, applying clinical judgment to develop and implement plans of care for members with complex needs. You will work with nurses and treating MDs, triage inquiries, and coordinate care across services.

This hybrid role requires 5+ years of nursing experience, transplant exposure, and CCM certification or active pursuit. Strong knowledge of guidelines and Medicare/PA processes is essential.

Qualifications

• Must hold a current CA RN License or RN license from another state; compact state preferred.
• Associate's Degree in Nursing is required.
• BSN or higher degree preferred.
• CCM Certification or in process of obtaining.
• Minimum 5 years of nursing/healthcare experience; transplant experience required.
• 3 years of managed care experience preferred.
• Ability to assess, evaluate, and interpret clinical information and care plans.
• Knowledge of evidence-based guidelines for chronic conditions.
• Demonstrates professional judgment and critical thinking for medical necessity.
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, LOS criteria desirable.
• Proficient with Microsoft Office 365 (Word, Excel, Outlook, Teams).

Responsibilities

• Determine, develop and implement the plan of care based on assessment and current treatment plans.
• Collaborate with members, clinical nurses and treating MDs as part of care management.
• Independently assess medical necessity promoting quality, cost-effective care.
• Report to the Manager, Care Management and contribute to team goals.

Skills

RN license

Assoc. Degree in Nursing

BSN or higher

CCM Certification

5+ years nursing/healthcare

Transplant experience

3 years managed care

Clinical assessment & care planning

Evidence-based guidelines knowledge

Medical necessity judgment

Coordination of Care/Medicare/PA/LOS

Office 365 proficiency

Education

Associate's Degree in Nursing

Bachelor of Science in Nursing or higher

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.

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.