Care Management - Nurse, Senior - Transplant

Blue Shield of CA; Springfield Meadows (CA); Hybride; USD 110 000 - 140 000; Plein temps

Résumé du poste

Blue Shield of CA is seeking a Senior Case Management Nurse to develop and implement individualized care plans. You will collaborate with members, clinical nurses, and treating physicians to ensure effective, evidence-based care and appropriate resource use.

Eligibility requires a CA RN license with possible multi-state licensure, CCM certification or progress toward it, and at least five years in nursing or healthcare. A transplant background and managed care experience are highly valued.

Qualifications

• Requires CA RN license and licensure in good standing.
• Associate degree in nursing required; BSN or higher preferred.

Responsabilités

• Develop and implement plans of care based on assessments and current treatment plans.
• Collaborate with members, nurses, and physicians to coordinate care.
• Assess, triage, and manage cases including chronic conditions and transplant-related needs.
• Apply evidence-based guidelines to determine medical necessity and care pathways.

Connaissances

CA RN License

CCM Certification

5+ years nursing/healthcare experience

Transplant experience

Managed care experience

Clinical assessment & care planning

Evidence-based guidelines knowledge

Medicare regulations knowledge

Professional judgment & critical think

Office 365 proficiency (Word, Excel, O

Formation

Associate's Degree in Nursing

BSN or higher degree preferred

Outils

Microsoft Office 365 (Word, Excel, Outlook, Teams)

Description du poste

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.