Senior Care Management Nurse - Hybrid & Impact

Blue Shield of CA; Los Angeles (CA); Hybrid; USD 90,000 - 110,000; Full time

Job summary

Blue Shield of California is seeking a Care Management professional to independently manage complex high-risk cases, apply clinical judgment to assess medical necessity, and develop cost-effective care plans in alignment with benefit requirements.

You will collaborate with providers and interdisciplinary teams, coordinate discharge planning, reassess plans, and participate in a rotating evening and weekend on-call schedule in a hybrid virtual work model.

Qualifications

• 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.
• Knowledge of community resources, home health services, funding sources, and specialty programs.
• Knowledge of regulatory and accreditation standards including CMS, DHCS, URAC, NCQA, DMHC, MHPAEA, and CA SB 855 is preferred.
• 3 years of managed care experience preferred

Responsibilities

• Collaborate with providers, medical directors, and interdisciplinary teams to coordinate care.
• Support discharge planning and evaluate barriers to care.
• Ensure members receive appropriate referrals and continuity of treatment.
• Ongoing reassessment of care plans and awareness of healthcare trends and guidelines.
• Participate in rotating evening and weekend on-call schedule.

Skills

Clinical assessment

Care coordination

On-call management

Regulatory knowledge

Evidence-based guidelines

Education

Associate Degree in Nursing

Bachelor of Science in Nursing

Job description

Blue Shield of California is seeking a Care Management professional to independently manage complex high-risk cases, apply clinical judgment to assess medical necessity, and develop cost-effective care plans in alignment with benefit requirements.

You will collaborate with providers and interdisciplinary teams, coordinate discharge planning, reassess plans, and participate in a rotating evening and weekend on-call schedule in a hybrid virtual work model.