Senior Nurse, Care Management — Hybrid Leader

Blue Shield of CA; Long Beach (CA); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of CA is seeking a care management professional to lead complex, high-risk cases by applying advanced clinical judgment in assessing medical necessity and developing cost-effective care plans. You will coordinate with providers, medical directors, and interdisciplinary teams to ensure appropriate referrals and continuity of treatment, with rotating on-call responsibilities.

The role emphasizes staying current on clinical guidelines, reassessing care plans, and supporting discharge

Qualifications

• Associate Degree in Nursing is required or a master's degree in a relevant field for non-RN licensure.
• Bachelor of Science in Nursing is preferred.
• 5 years of experience in nursing, healthcare, or a related clinical field.
• 3 years of managed care experience preferred.
• Certified Case Manager (CCM) is 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, 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

• 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.
• Engage in ongoing reassessment of care plans and stay updated on healthcare trends and clinical guidelines.
• Participate in a rotating evening and weekend on-call schedule.

Education

Associate Degree in Nursing

Bachelor of Science in Nursing

Master's degree in relevant field

Job description

Blue Shield of CA is seeking a care management professional to lead complex, high-risk cases by applying advanced clinical judgment in assessing medical necessity and developing cost-effective care plans. You will coordinate with providers, medical directors, and interdisciplinary teams to ensure appropriate referrals and continuity of treatment, with rotating on-call responsibilities.

The role emphasizes staying current on clinical guidelines, reassessing care plans, and supporting discharge