Care Management - Nurse, Senior - Transplant

Blue Shield of CA; Houston (TX); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of CA is seeking a Senior Case Management Nurse to lead case management activities with clinical judgment and independent analysis. You will collaborate with members, nurses and treating physicians to develop and implement care plans based on comprehensive assessments.

This role addresses chronic conditions, poly-pharmacy, prenatal care, and high ER visit patterns. Qualified candidates have an active RN license, 5+ years of nursing/healthcare experience, transplant exposure, and CCM

Qualifications

• Requires CA RN license or license from another state with compact licensure preferred.
• Associate's Degree in Nursing is required.
• BSN or higher degree preferred.
• CCM certification or in progress when eligible.

Responsibilities

• Perform case management activities with clinical judgment and independent analysis.
• Collaborate with members, nurses and treating physicians involved in care.
• Determine and implement care plans based on assessments and treatment plans.
• Address cases including chronic conditions, polypharmacy, prenatal care and high ER utilization.
• Utilize professional judgment to promote appropriate, cost-effective care.

Skills

RN license

5+ years experience

Transplant experience

Managed care experience

Independent assessment

Evidence-based guidelines

Medical necessity judgment

Coordination of Care knowledge

Medicare regulations knowledge

MS Office 365 proficiency

Education

Associate's Degree in Nursing

BSN or higher

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.

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.