Senior Care Coordination RN - Triage & Case Mgmt

Blue Shield of California; California; Hybrid; USD 91,000 - 136,000; Full time

Benefits offered by this job

Hybrid work model

Job summary

Blue Shield of California is seeking a Complex Care Coordination Triage Registered Nurse Case Manager to perform integrated case and disease management. You will assess member needs, develop care plans, and coordinate across care teams to ensure high-quality, cost-effective outcomes.

You will manage referrals, educate members on chronic conditions, and navigate care transitions, with a focus on timely access to services and adherence to NCQA standards.

Qualifications

• Associate Degree in Nursing is required.
• Active, unrestricted RN license in CA is required.
• Requires at least 5 years of prior experience in nursing, healthcare or related field.
• CCM Certification is preferred.

Responsibilities

• Conduct provider searches and assist members in accessing medically necessary services within the access network and plan benefits.
• Triage referrals from the 24-hours Nurse Line to ensure timely provider access and education on health conditions.
• Initiate the Letter of Agreement (LOA) and Exception process with providers and internal departments.
• Provide disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and CAD) and rare conditions.
• Outreach to members with HEDIS Care Gaps to assist with closure.
• Perform discharge planning and collaborate with the member support system and care team.
• Coordinate transition to lower levels of care as appropriate (skilled nursing, home health, etc.).
• Demonstrate professional judgment and critical thinking to promote quality, cost-effective care.
• Develop and update individualized care plans based on medical and behavioral health needs.

Skills

Supervisory skills

Communication skills

Verbal communication

Written communication

Negotiation skills

Problem solving

Critical thinking

Knowledge of NCQA/regulatory

Leadership

Education

Associate Degree in Nursing

Bachelor of Science in Nursing or advanced degree

RN license in CA

CCM Certification

Tools

Word

Excel

Job description

Blue Shield of California is seeking a Complex Care Coordination Triage Registered Nurse Case Manager to perform integrated case and disease management. You will assess member needs, develop care plans, and coordinate across care teams to ensure high-quality, cost-effective outcomes.

You will manage referrals, educate members on chronic conditions, and navigate care transitions, with a focus on timely access to services and adherence to NCQA standards.