Senior Care Management Nurse - Hybrid & Impactful Leader

Blue Shield of CA; Rancho Cordova (CA); Hybrid; USD 85,000 - 120,000; Full time

Job summary

Blue Shield of CA is seeking a Care Management professional to oversee complex cases, applying clinical judgment to develop cost-effective care plans and ensure continuity of treatment. You will collaborate with providers, medical directors, and interdisciplinary teams to coordinate care and support discharge planning.

The role requires a nursing background with strong knowledge of evidence-based guidelines, and a willingness to participate in rotating evening and weekend on-call shifts.

Qualifications

• Associate Degree in Nursing required or master's 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.
• Advanced knowledge of evidence based clinical practice guidelines, particularly for chronic conditions.
• Knowledge of community resources, treatment options, 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.
• 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 ensure appropriate referrals and continuity of treatment.
• Continuously reassess care plans and evaluate barriers to care in line with clinical guidelines.
• Support discharge planning and connect members with community resources and home health services.
• Be available for rotating evening and weekend on-call schedule.

Skills

5+ years experience

Managed care experience

Clinical assessment

Clinical guidelines

Care coordination

Regulatory standards

Discharge planning

On-call scheduling

Education

Associate Degree in Nursing

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

Bachelor of Science in Nursing (BSN)

Job description

Blue Shield of CA is seeking a Care Management professional to oversee complex cases, applying clinical judgment to develop cost-effective care plans and ensure continuity of treatment. You will collaborate with providers, medical directors, and interdisciplinary teams to coordinate care and support discharge planning.

The role requires a nursing background with strong knowledge of evidence-based guidelines, and a willingness to participate in rotating evening and weekend on-call shifts.