Hybrid: Senior Care Manager - Complex Case Coordination

Blue Shield of CA; Oakland (CA); Hybrid; USD 120,000 - 150,000; Full time

Job summary

Blue Shield of CA is seeking a Care Management professional to lead complex and high-risk cases, applying advanced clinical judgment to evaluate medical necessity and develop cost-effective, quality-focused care plans. You will collaborate with providers, medical directors, and interdisciplinary teams to coordinate care, support discharge planning, and ensure continuity of treatment, while reassessing plans and staying current with guidelines.

A rotating on-call schedule is required.

Qualifications

• Associate degree in nursing required or master's degree in relevant field for non-RN licensure.
• Bachelor of Science in Nursing preferred.
• 5 years of experience in nursing, healthcare, or a related clinical field.
• 3 years of managed care experience preferred.
• Certified Case Manager (CCM) preferred.
• Ability to independently assess, evaluate, and interpret complex clinical information and care plans.
• Advanced knowledge of evidence based clinical practice guidelines, particularly for chronic conditions.
• Demonstrated competence in care management functions and standards of practice.
• Knowledge of community resources, treatment options, home health services, funding sources, and specialty programs.
• Working knowledge of regulatory and accreditation standards including CMS, DHCS, URAC, NCQA, DMHC, MHPAEA, and CA SB 855 is preferred.
• Knowledge of coordination of care, government and commercial regulations, prior authorization processes, and level of care and length of stay criteria is preferred.

Responsibilities

• Coordinate care with providers, medical directors, and interdisciplinary teams to manage complex cases.
• Support discharge planning and ensure referrals and continuity of treatment.
• Continuously reassess care plans and stay updated with clinical guidelines and trends.
• Participate in rotating evening and weekend on-call scheduling.

Skills

Clinical judgment

Care coordination

Interdisciplinary collaboration

On-call management

Education

Associate Degree in Nursing

Bachelor of Science in Nursing

Master's degree in relevant field (non-RN licensure)

Job description

Blue Shield of CA is seeking a Care Management professional to lead complex and high-risk cases, applying advanced clinical judgment to evaluate medical necessity and develop cost-effective, quality-focused care plans. You will collaborate with providers, medical directors, and interdisciplinary teams to coordinate care, support discharge planning, and ensure continuity of treatment, while reassessing plans and staying current with guidelines.

A rotating on-call schedule is required.