Care Management - Nurse, Senior - Transplant

Blue Shield of CA; Virginia Beach (VA); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of CA is seeking a Senior Case Management Nurse to lead and execute care planning with a strong clinical focus. The role involves assessing members and developing plans in collaboration with nurses and treating physicians, particularly around chronic conditions and high ER utilization.

The position requires an active RN license, a nursing degree (BSN preferred), and CCM certification or progress toward certification. Hybrid virtual work is available with occasional in-office needs.

Qualifications

• Requires a CA RN license or valid RN license in another state.
• Associate's Degree in Nursing is required.
• BSN or higher degree is preferred.
• CCM certification or in progress when eligible.
• At least 5 years of nursing, healthcare, or related experience.
• Prior transplant experience is required.
• Desires 3 years of managed care experience.
• Ability to assess, evaluate, and interpret clinical information for care planning.
• Extensive knowledge of evidence-based clinical guidelines for chronic conditions.
• Knowledge of Medicare regulations, prior authorization, level of care and LOS criteria.
• Proficient with PC-based software including Word, Excel, Outlook and Teams.

Responsibilities

• Determine, develop and implement the plan of care based on accurate assessment.
• Collaborate with members, clinical nurses and treating MDs on care planning.
• Triagem hub, chronic conditions, poly-pharmacy, prenatal care, and health assessments.
• Apply professional judgment to determine medical necessity and quality care.

Skills

RN license

CCM Certification

Associate's Degree in Nursing

BSN preferred

5+ years nursing experience

Transplant experience

Managed care experience

Clinical assessment

Evidence-based guidelines

Medicare coordination

Office 365 proficiency

Care coordination knowledge

Critical thinking

Education

Associate's Degree in Nursing

Bachelor of Science in Nursing or higher

Tools

Microsoft Office 365

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.