Care Management - Nurse, Senior - Transplant

Blue Shield of CA; Seattle (WA); Hybrid; USD 110,000 - 150,000; Full time

Job summary

Blue Shield of CA is seeking a Senior Case Management Nurse to lead care planning with a focus on clinical judgment and independent analysis. You will assess members, develop care plans, and collaborate with nurses and treating physicians to ensure high-quality, cost-effective care.

The hybrid virtual role supports off-site work with periodic in-office needs. The ideal candidate has an active RN license, 5+ years in nursing or healthcare, and transplant experience, with CCM certification

Qualifications

• Requires a current and valid CA RN License or license from other state(s) with active, unrestricted status
• Requires an Associate's Degree in Nursing
• BSN or higher degree preferred
• CCM certification or in process of completion when eligible
• At least 5 years of nursing/healthcare experience
• Prior transplant experience is required
• 3 years of managed care experience desired
• Ability to independently assess, evaluate, and interpret clinical information for care planning
• Extensive knowledge of evidence-based guidelines for chronic conditions
• Knowledge of Coordination of Care, Medicare regulations, and prior authorization desirable
• Proficiency with Microsoft Office 365 (Word, Excel, Outlook, Teams)

Responsibilities

• Determine, develop and implement the plan of care based on accurate assessment and current or proposed treatment plan
• Collaborate with members, nurses, treating MDs and other care team members
• Triage hub cases including chronic conditions, poly-pharmacy and prenatal care
• Assess medical necessity using professional judgment to promote quality and cost-effective care
• Coordinate care with adherence to Medicare guidelines and length of stay criteria
• Support voluntary member health assessments and ER visit indicators

Skills

RN licensure

Case management

Critical thinking

Medical necessity evaluation

Coordination of Care

Medicare regulations

Microsoft Office 365

Education

Associate Degree in Nursing

BSN or higher

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft 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.