Care Management - Nurse, Senior - Transplant

Blue Shield of CA; Milwaukee (WI); Hybrid; USD 85,000 - 110,000; Full time

Benefits offered by this job

Hybrid work option

Job summary

The Case Management Nurse, Senior role supports the Case Management team by applying clinical judgment and independent analysis to develop and implement care plans. It involves triage, chronic conditions management, poly-pharmacy considerations, prenatal care, and evaluating high ER visits.

Hybrid virtual work is available with office visits as needed. Qualifications include an active RN license (CA or compact state), Associate's Degree in Nursing, BSN preferred, CCM certification, and multiple

Qualifications

• Requires an active RN license (CA or compact state) in assigned state(s).
• Associate's Degree in Nursing required.
• BSN or advanced degree preferred.
• CCM Certification or in process.

Responsibilities

• Determine, develop and implement the care plan based on assessment and treatment plans.
• Collaborate with members, nurses and treating MDs in care management.
• Assess, evaluate and interpret clinical information for appropriate care planning.
• Apply evidence-based guidelines for chronic conditions and medical necessity decisions.

Skills

Critical thinking

Independent analysis

Clinical judgment

Microsoft Office 365

Education

Associate's Degree in Nursing

Bachelor of Science in Nursing

Tools

MS 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.