Senior Care Management Nurse - Hybrid/Remote, On-Call

Blue Shield of CA; Redding (CA); Hybrid; USD 110,000 - 160,000; Full time

Job summary

Blue Shield of CA seeks a Care Management leader to independently manage complex, high-risk cases, applying advanced clinical judgment to assess medical necessity and develop cost-effective care plans. You will collaborate with providers, medical directors, and interdisciplinary teams to coordinate care and support discharge planning.

This role requires ongoing reassessment of care plans, awareness of healthcare trends and guidelines, and participation in a rotating on-call schedule.

Qualifications

• Associate Degree in Nursing required or master's degree for non-RN licensure.
• Bachelor of Science in Nursing preferred.
• 5 years of experience in nursing, healthcare, or 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.
• Knowledge of coordination of care, government and commercial regulations, prior authorization processes, and criteria.
• Familiarity with CMS, DHCS, URAC, NCQA, DMHC, MHPAEA, and CA SB 855.

Responsibilities

• Collaborate with providers, medical directors and interdisciplinary teams to coordinate care.
• Support discharge planning and evaluate barriers to care for members.
• Ensure members receive appropriate referrals and continuity of treatment.
• Reassess care plans and stay current with healthcare trends and clinical guidelines.

Skills

Nursing

CCM

Care management

Clinical guidelines

Education

Associate Degree in Nursing

Bachelor of Science in Nursing

Master's degree in relevant field

Job description

Blue Shield of CA seeks a Care Management leader to independently manage complex, high-risk cases, applying advanced clinical judgment to assess medical necessity and develop cost-effective care plans. You will collaborate with providers, medical directors, and interdisciplinary teams to coordinate care and support discharge planning.

This role requires ongoing reassessment of care plans, awareness of healthcare trends and guidelines, and participation in a rotating on-call schedule.