Care Management - Nurse, Senior - Transplant

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

Job summary

Blue Shield of CA is seeking a Senior Case Management Nurse to join the Case Management team. You will determine, develop, and implement plans of care based on accurate member assessment, current or proposed treatment plans, and coordination with clinicians and care teams.

The role emphasizes independent analysis for chronic conditions, polypharmacy, prenatal care, and addressing frequent ER visits, with hybrid virtual work and periodic office attendance.

Qualifications

• Currently licensed RN in CA or other states; compact state licensure preferred; must maintain active license in assigned state(s)
• Associate's Degree in Nursing required
• BSN or higher degree preferred
• CCM certification or in process
• At least 5 years of nursing/healthcare experience
• Prior transplant experience required
• 3 years of managed care experience preferred
• Ability to independently assess, evaluate, and interpret clinical information and care planning
• Extensive knowledge of evidence-based clinical practice guidelines for chronic conditions
• Judgment and critical thinking to determine medical necessity for quality/cost-effective care
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and LOS criteria
• Proficiency in PC-based software including Word, Excel, Outlook and Teams

Responsibilities

• Determine, develop and implement the plan of care based on accurate assessment and current or proposed treatment plan in collaboration with members and care teams
• Collaborate with members, nurses, treating MDs and care teams to manage cases including high ER visits and complex needs

Skills

RN licensing and regulation

Critical thinking

Care planning

Independent assessment

Medical necessity evaluation

Chronic care guidelines

Coordination of care

Office 365 proficiency

Education

Associate's Degree in Nursing

BSN or higher degree preferred

CCM Certification or in progress

Tools

Microsoft Word

Excel

Outlook

Teams

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.